NCLEX-PN
Safe and Effective Care Environment Nclex PN Questions
1. When a client has a chest drainage system in place, where should the system be placed?
- A. above the level of the client's chest
- B. at the level of the client's shoulders
- C. at the level of the chest
- D. below the level of the chest
Correct answer: D
Rationale: A chest drainage system should be placed below the level of the client's chest to ensure proper drainage of fluid from the chest. Placing the system above the level of the chest or at the shoulders would not allow gravity to assist in the drainage process, potentially leading to complications such as fluid accumulation. Similarly, placing it at the level of the chest would not create the necessary gravity-dependent flow for effective drainage, which is crucial for the proper functioning of the chest drainage system.
2. While repositioning a comatose client, the nurse senses a tingling sensation as she lowers the bed. What action should she take?
- A. Unplug the bed's power source.
- B. Remove the client from the bed immediately.
- C. Notify the biomedical department at once.
- D. Turn off the oxygen.
Correct answer: A
Rationale: The correct action for the nurse to take when sensing a tingling sensation while lowering the bed with a comatose client is to unplug the bed's power source. This should be the initial step as there may be a fault in the bed's grounding. Removing the client from the bed immediately is not safe until the electrical issue is resolved. Notifying the biomedical department is important but should come after ensuring the immediate safety of the client. Turning off the oxygen is not necessary unless there is a specific issue related to oxygen delivery, which is not indicated in this scenario.
3. The LPN is auscultating for bowel sounds and hears between 3 and 4 bowel sounds per minute. This is a somewhat expected finding for which of these clients?
- A. a 63-year-old female undergoing chemotherapy for breast cancer
- B. a 56-year-old female with dementia undergoing a swallow study
- C. a 34-year-old male with a PEG tube newly admitted for diabetic ketoacidosis
- D. a 45-year-old male recovering from a knee replacement under general anesthesia
Correct answer: D
Rationale: When recovering from general anesthesia, hypoactive bowel sounds can be expected due to the effects of the anesthesia on gut motility. For the other clients, hearing less than 5 bowel sounds per minute would indicate an abnormal finding. In the context of the given situation, the client recovering from knee replacement surgery aligns with the expected range of bowel sounds post-general anesthesia. Therefore, choice D is the correct answer. Choices A, B, and C present scenarios where hearing less than 5 bowel sounds per minute would be abnormal, indicating potential issues that need further evaluation.
4. What spinal change occurring with pregnancy alters mobility?
- A. Scoliosis.
- B. Kyphosis.
- C. Lordosis.
- D. Ankylosing spondylitis.
Correct answer: C
Rationale: The correct answer is 'Lordosis.' During pregnancy, the enlarging uterus places increased weight on the spine, causing an exaggerated inward curvature known as lordosis. This change alters mobility by shifting the center of gravity forward, leading to a compensatory change in posture. Scoliosis (choice A) is a sideways curvature of the spine, not typically associated with pregnancy. Kyphosis (choice B) is an exaggerated outward curvature of the spine, while ankylosing spondylitis (choice D) is a chronic inflammatory condition affecting the spine, neither of which are directly related to the spinal changes seen in pregnancy.
5. The LPN is caring for a client with an NG tube, and the RN administers evening medications through the NG tube. The client asks if he can lie down when the nurse leaves the room. What is the most appropriate response?
- A. You can lie down in 1 hour.
- B. You can lie down in 30 minutes if your NG residual is below 50 mL.
- C. You can lie down in about 30 minutes.
- D. Yes, feel free to lie down.
Correct answer: A
Rationale: After administering medication through an NG tube, the client should remain upright for 30 minutes to ensure proper absorption of the medications. Therefore, the most appropriate response is to advise the client to lie down in 1 hour. Choice B is incorrect because waiting only 30 minutes may not provide sufficient time for the medications to be fully absorbed, as the recommended time is 30 minutes. Choice C is misleading as it incorrectly suggests that lying down in about 30 minutes is acceptable, which could compromise medication effectiveness. Choice D is incorrect as it does not provide accurate information regarding the appropriate timing for lying down after NG tube medication administration, potentially leading to decreased medication absorption.
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