NCLEX-PN
Safe and Effective Care Environment Nclex PN Questions
1. Which type of diet should the nurse provide to help a client who has major burns maintain a positive nitrogen balance?
- A. high protein
- B. high carbohydrate
- C. low carbohydrate
- D. low protein
Correct answer: A
Rationale: Clients with major burns are in a hypermetabolic state, leading to increased protein catabolism. Therefore, a high-protein diet is essential to help them maintain a positive nitrogen balance and support wound healing. High carbohydrate diets do not directly contribute to achieving a positive nitrogen balance, making choice B incorrect. Similarly, low carbohydrate diets are not recommended for clients with major burns as carbohydrates provide essential energy needed for healing. Low protein diets are contraindicated for clients with major burns as they require higher protein intake to support tissue repair and prevent further breakdown.
2. 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.
3. A 45-year-old client with type I diabetes is in need of support services upon discharge from a skilled rehabilitation unit. Which of the following services is an example of a skilled support service?
- A. shopping for groceries
- B. house cleaning
- C. transportation to physician's visits
- D. medication instruction
Correct answer: D
Rationale: The correct answer is 'medication instruction.' This service involves educating the client on how to properly take their medications, which requires a certain level of expertise and skill. Grocery shopping, house cleaning, and transportation to physician's visits are considered unskilled services as they do not involve specialized knowledge or training. In contrast, medication instruction is a skilled service that necessitates specific training to ensure the client's safety and adherence to their medication regimen.
4. To remove hard contact lenses from an unresponsive client, what should the nurse do?
- A. Gently irrigate the eye with an irrigating solution from the inner canthus outward
- B. Grasp the lens with a gentle pinching motion
- C. Don sterile gloves before attempting the procedure
- D. Ensure that the lens is centered on the cornea before gently manipulating the lids to release the lens
Correct answer: D
Rationale: When removing hard contact lenses from an unresponsive client, the nurse should ensure that the lens is centered on the cornea before gently manipulating the lids to release the lens. This approach helps prevent scratching the cornea. Gently maneuvering the upper and lower eyelids assists in loosening the lens for easy removal. Options A, B, and C are incorrect because irrigating the eye, grasping the lens, or wearing sterile gloves are not recommended methods for removing hard contact lenses. It is crucial to handle the situation delicately to avoid causing harm or discomfort to the client.
5. A client with cirrhosis of the liver presents with ascites. The physician is to perform a paracentesis. For safety, the nurse should ask the client to:
- A. drink 1000 cc of fluid prior to the procedure to aid in fluid loss.
- B. eat foods low in fat.
- C. empty his bladder prior to the procedure.
- D. assume the prone position.
Correct answer: C
Rationale: When performing a paracentesis, the client must be sitting up to allow the fluid to settle in the lower abdomen. To prevent trauma to the bladder while inserting a needle to aspirate the fluid, the bladder must be empty. Choice A is incorrect as excessive fluid intake can make the procedure more difficult due to increased abdominal distension. Choice B is unrelated to the procedure of paracentesis. Choice D is incorrect as the client should be sitting up, not in the prone position, during the procedure.
Similar Questions
Access More Features
NCLEX PN Basic
$69.99/ 30 days
- 5,000 Questions with answers
- Comprehensive NCLEX coverage
- 30 days access @ $69.99
NCLEX PN Premium
$149.99/ 90 days
- 5,000 Questions with answers
- Comprehensive NCLEX coverage
- 30 days access @ $149.99