NCLEX-PN
Safe and Effective Care Environment Nclex PN Questions
1. A client is on a clear liquid diet. She drinks half of a 12-ounce juice, 4 ounces of soup, and has a 6-ounce JELLO�. How many milliliters of fluid did the patient ingest?
- A. 440 ml
- B. 480 ml
- C. 220 ml
- D. 660 ml
Correct answer: B
Rationale: To calculate the total amount of fluid ingested, convert the ounces to milliliters. Given that 1 ounce is equal to 30 ml, the breakdown is as follows: Juice (6 ounces): 6 x 30 = 180 ml. Soup (4 ounces): 4 x 30 = 120 ml. JELLO� (6 ounces): 6 x 30 = 180 ml. Adding these together: 180 ml (juice) + 120 ml (soup) + 180 ml (JELLO�) = 480 ml. Therefore, the patient ingested a total of 480 ml of fluid. It's important to note that gelatin, ice cream, and similar items that are liquid at room temperature should be considered as fluids. Choice A, 440 ml, is incorrect as it does not account for the correct calculation. Choice C, 220 ml, is incorrect as it is significantly lower than the correct total. Choice D, 660 ml, is incorrect as it overestimates the total fluid intake.
2. In a disaster situation, the nurse assessing a diabetic client on insulin assesses for all of the following except:
- A. diabetic signs and symptoms.
- B. nutritional status.
- C. bleeding problems.
- D. availability of insulin.
Correct answer: C
Rationale: In a disaster situation, when assessing a diabetic client on insulin, the nurse needs to consider various factors. Diabetic signs and symptoms, nutritional status, and availability of insulin are crucial aspects to assess for appropriate management during a crisis. However, bleeding problems are not directly related to diabetes or insulin therapy. Therefore, assessing for bleeding problems is not a priority in this context. Choice C, bleeding problems, is the correct answer as it is not typically associated with diabetes, unlike the other options provided.
3. Which fetal heart monitor pattern can indicate cord compression?
- A. variable decelerations
- B. early decelerations
- C. bradycardia
- D. tachycardia
Correct answer: A
Rationale: Variable decelerations can indicate cord compression as they are caused by umbilical cord compression or prolapse. This pattern shows an abrupt decrease in heart rate with an erratic shape, often resembling a V or W. Early decelerations (choice B) are typically caused by head compression during contractions and are considered benign. Bradycardia (choice C) is a consistent low heart rate below 110 bpm and is not specific to cord compression. Tachycardia (choice D) is an abnormally high heart rate above 160 bpm and is not associated with cord compression.
4. What does carrying a donor card for organ donation mean?
- A. medical care is altered to obtain organs for donation in the event of serious injuries
- B. the family or legally responsible party of a client has no decision-making authority in the event that the client is considered for organ donation
- C. a client is allowed to revoke their decision for organ donation at any time
- D. a client is considered an organ donor for multiple organs or tissues
Correct answer: C
Rationale: Carrying a donor card for organ donation signifies that an individual can decide to revoke their decision for organ donation at any point. This choice empowers the individual to change their mind regarding organ donation. The family or legally responsible party of a client still holds decision-making authority in the event that the client is considered for organ donation. When organ donation is being considered, all organs or tissues the donor wishes to donate are evaluated for donation suitability; it's not limited to just one organ or tissue. It's important to note that medical care for an individual is not altered to hasten the declaration of death for organ donation purposes; the focus is on providing immediate care and resuscitation to the individual.
5. What is the purpose of the hydraulic lift (Hoyer lift)?
- A. To assist clients who have had orthopedic surgery.
- B. To assist clients who are unable to stand and extremely obese clients.
- C. To assist clients of all ages in a hospital setting.
- D. To assist clients with special needs.
Correct answer: B
Rationale: The purpose of the hydraulic lift, also known as the Hoyer lift, is to facilitate safe transfers for clients who cannot stand or are extremely obese. It is specifically designed for assisting clients who are unable to stand and for those who are too heavy for healthcare workers to lift safely. Choice A is incorrect because the primary purpose of a hydraulic lift is not related to orthopedic surgery. Choice C is incorrect because it is too broad and does not capture the specific use of the hydraulic lift. Choice D is incorrect because the lift is not solely for clients with special needs but rather for those who cannot stand or are extremely obese.
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