NCLEX-PN
Safe and Effective Care Environment Nclex PN Questions
1. Which of the following statements indicates that the provider understands how to promote rest and sleep for the client?
- A. If you would prefer not to be disturbed, we can postpone all vital signs and assessments until tomorrow morning.
- B. With your physical therapy appointments, you cannot nap more during the day even if your sleep is often interrupted at nighttime.
- C. I can try to incorporate any sleep rituals or an ideal bedtime into your routine.
- D. We cannot group together medications, assessments, and other interventions so you may have multiple interruptions at night.
Correct answer: C
Rationale: The correct answer is, 'I can try to incorporate any sleep rituals or an ideal bedtime into your routine.' To promote rest and sleep, the provider should consider incorporating the client's preferred sleep rituals or bedtime routine. This statement shows an understanding of the importance of individualizing care to promote restful sleep. Choices A, B, and D do not directly address promoting rest and sleep. Choice A focuses on postponing assessments, Choice B addresses napping during the day, and Choice D mentions multiple interruptions at night, none of which directly support promoting rest and sleep for the client.
2. What is the best definition of ethics in nursing?
- A. advocating for the client
- B. knowing your scope of practice
- C. being able to differentiate right from wrong
- D. being willing to report violations
Correct answer: C
Rationale: Ethics in nursing refers to the moral principles that govern a nurse's behavior and decision-making. It involves being able to differentiate right from wrong, making choices that are morally sound, and upholding integrity in patient care. While advocating for the client (choice A) is an important aspect of nursing care, it does not fully encompass the broad concept of ethics. Knowing your scope of practice (choice B) is essential for safe and competent care but is not a comprehensive definition of ethics. Being willing to report violations (choice D) is part of ethical practice, but it is not the core definition of ethics in nursing.
3. What is the most effective way to prevent skin breakdown?
- A. assistive devices
- B. repositioning
- C. topical medications
- D. avoiding tape and bandages
Correct answer: V
Rationale: Repositioning is the most effective way to prevent skin breakdown. Repositioning helps relieve pressure on specific areas of the skin, reducing the risk of developing pressure ulcers. While assistive devices (Choice A) may be beneficial in some cases, they are not universally as effective as repositioning. Topical medications (Choice C) are primarily used for treating skin conditions and are not the primary focus for preventing skin breakdown. Avoiding tape and bandages (Choice D) is crucial to prevent skin irritation, but repositioning remains the most effective method to prevent skin breakdown.
4. The nurse is preparing to administer the 9 am dose of IV antibiotics when she notes the IVAC cord is frayed with wiring visible. What action should be her priority for this client?
- A. Notify maintenance to come and check the pump immediately.
- B. Continue with the administration of the antibiotic and fill out an equipment maintenance request.
- C. Immediately discontinue the use of this IVAC pump and obtain a replacement.
- D. Tag the equipment for maintenance.
Correct answer: C
Rationale: The correct action is to immediately discontinue the use of the IVAC pump and obtain a replacement because the frayed cord poses a safety risk to the client. Continuing to use the pump with visible wiring could lead to electric shock or other serious harm to the client. Notifying maintenance to come and check the pump immediately (Choice A) may cause unnecessary delays in ensuring the client's safety. Continuing with the administration of the antibiotic and filling out an equipment maintenance request (Choice B) is unsafe as it ignores the immediate danger. Tagging the equipment for maintenance (Choice D) does not address the urgent need to protect the client from harm.
5. Which of the following clients would be most appropriate for an LPN to assign to a nursing assistant?
- A. an 18-year-old client with a femur fracture who is just returning to the floor from the recovery unit
- B. an 84-year-old client 2 days post-op after knee replacement surgery who needs help ambulating
- C. a 35-year-old client who is suffering from an acute asthma attack
- D. a 20-year-old client with Cystic Fibrosis who needs an early morning sputum sample collection
Correct answer: D
Rationale: Collecting sputum samples on stable clients is within the scope of practice for an LPN. This task does not require immediate intervention or assessment by an RN or medical provider. An RN should perform the initial assessment on any client immediately post-op as it requires a higher level of assessment and monitoring. A client suffering from an acute asthma attack should be attended to by an RN or medical provider due to the potential severity and need for prompt intervention. Assigning a medically stable client who needs help ambulating to a nursing assistant is appropriate as it falls within their scope of practice and allows the LPN to focus on tasks that require their expertise.
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