NCLEX-PN
Safe and Effective Care Environment Nclex PN Questions
1. Which of the following devices may be applicable to a bedridden patient to address potential venous insufficiency?
- A. Shear-reducing mattress
- B. Sequential compression devices
- C. Hiking stockings
- D. Non-skid socks
Correct answer: B
Rationale: For a bedridden patient with potential venous insufficiency, sequential compression devices (SCDs) and compression stockings are appropriate choices. SCDs help improve venous return from the lower extremities by applying sequential pressure, aiding circulation. Compression stockings also assist in preventing blood from pooling in the legs by applying pressure to support venous return. Shear-reducing mattresses are not directly related to managing venous insufficiency, as they are designed to reduce friction and shear forces on the skin to prevent pressure ulcers. Non-skid socks are primarily used for fall prevention and have no direct impact on venous insufficiency.
2. An LPN is working on the care plan for a client with diabetes mellitus. Which of these outcomes would be the most appropriate?
- A. The client will maintain a blood glucose level within the normal range of 70-110 (per facility policy) throughout my shift.
- B. The client will maintain a blood glucose level within normal range limits today.
- C. The client will maintain a blood glucose level within the normal range of 70-110 (per facility policy) throughout my shift.
- D. The client will maintain a blood glucose level within normal limits throughout my shift.
Correct answer: C
Rationale: The correct answer is 'The client will maintain a blood glucose level within the normal range of 70-110 (per facility policy) throughout my shift.' This outcome is specific, measurable, and aligns with the goal of managing diabetes mellitus. Choice A is correct because it provides a clear target range (70-110) and includes adherence to facility policy, making it precise and goal-oriented. Choice B lacks specificity on the timeframe, and Choice D is vague in defining the target blood glucose range. In nursing care plans, outcomes should be well-defined, achievable, and measurable to effectively monitor the client's progress in managing their condition.
3. A nurse is assisting with data collection of a client who has sustained circumferential burns of both legs. What should the nurse examine first?
- A. Heart rate
- B. Peripheral pulses
- C. Blood pressure (BP)
- D. Radial pulse rate
Correct answer: B
Rationale: The priority assessment for a client with circumferential burns to the legs is to examine peripheral pulses. This is essential to ensure adequate circulation to the extremities. Circumferential burns can lead to compartment syndrome, causing decreased circulation to the affected limbs. Checking peripheral pulses is crucial to monitor for any signs of compromised circulation. While heart rate and blood pressure are important assessments in general, in the context of circumferential burns, the immediate concern is the risk of impaired circulation to the extremities. Therefore, assessing peripheral pulses takes precedence in this situation.
4. In a community hospital, a nurse is employed as a staff nurse and is supervised by a nurse manager. The nurse understands that in this position, the term authority most appropriately refers to which description?
- A. Accepting responsibility for the actions of others
- B. The official power to ensure that an organizational decision is enforced
- C. Bearing the legal responsibility for others' performance of tasks
- D. Taking responsibility for what staff members do
Correct answer: B
Rationale: The term authority refers to the official power of an individual to approve or command an action or to ensure that a decision is enforced. In the context of the nurse's position supervised by a nurse manager, having authority means having the official power to ensure that organizational decisions are carried out. Choice A, accepting responsibility for the actions of others, is more related to accountability rather than authority. Choice C, bearing the legal responsibility for others' performance of tasks, is more about legal liability rather than authority. Choice D, taking responsibility for what staff members do, is similar to choice A and is more about accountability rather than having the official power to enforce decisions. Therefore, the correct answer is B as it directly relates to the concept of authority in the context described.
5. Which of the following foods present a problem for a client diagnosed with Celiac Disease?
- A. butter
- B. oats or barley cereal
- C. fresh vegetables
- D. coffee or tea
Correct answer: B
Rationale: Celiac disease, also known as celiac sprue, is a malabsorption disorder affecting the small intestine due to a problem with ingesting gluten, a protein found in wheat, rye, oats, and barley. Therefore, oats or barley cereal would present a problem for a client with Celiac Disease as they contain gluten. Fresh vegetables, butter, coffee, and tea, on the other hand, do not contain gluten and should not pose any issues for individuals with this disorder. Therefore, the correct answer is oats or barley cereal. Choices A, C, and D are not problematic for clients with Celiac Disease as they are gluten-free.
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