NCLEX-PN
Safe and Effective Care Environment Nclex PN Questions
1. The LPN is caring for a 32-year-old female client who is 8 hours post-op after a tonsillectomy. Which of these actions would be appropriate for the nurse to take?
- A. Inform the client that ear pain may occur and is normal.
- B. Provide ice water and a straw to promote easy fluid consumption.
- C. Provide hot tea to soothe the throat.
- D. Monitor vitals every 15 minutes.
Correct answer: A
Rationale: The appropriate action for the nurse to take is to inform the client that ear pain may occur and is normal after a tonsillectomy. Referred pain in the ear is common due to related nerve pathways. It is essential to educate the client about this to alleviate concerns. Providing ice water and a straw is not recommended as they may irritate the throat and disturb the healing process. Hot beverages like tea should also be avoided for the same reason. While monitoring vitals every 15 minutes is crucial in the immediate postoperative period for early identification of any complications, it is not the most appropriate action in this scenario where addressing the client's concerns and providing education is key.
2. All of the following interventions should be performed when fetal heart monitoring indicates fetal distress except:
- A. increase maternal fluids
- B. administer oxygen
- C. decrease maternal fluids
- D. turn the mother
Correct answer: C
Rationale: When fetal distress is indicated, interventions are aimed at improving oxygenation and blood flow to the fetus. Increasing maternal fluids helps improve blood flow and oxygen delivery, administering oxygen increases oxygenation levels, and turning the mother can help optimize fetal oxygenation. Decreasing maternal fluids would negatively impact blood volume and can worsen fetal distress, making it the exception among the listed interventions. Therefore, decreasing maternal fluids should not be performed when fetal distress is present.
3. 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.
4. How should the LPN document pain for a non-verbal client using the FLACC pain scale with these findings?
- A. 1
- B. 4
- C. 3
- D. 2
Correct answer: B
Rationale: The correct answer is B: '4'. The FLACC pain scale assesses pain in non-verbal patients based on five categories: Face, Legs, Activity, Cry, and Consolability. In this case, the client exhibits occasional grimacing (1 point), relaxed legs (0 points), squirming (1 point), moans and whimpers (1 point), and is distractible (1 point). Adding these points together results in a total pain score of 4. Therefore, the LPN should document a pain score of 4 for this non-verbal client. Choices A, C, and D are incorrect as they do not accurately reflect the total pain score based on the given findings.
5. When making an occupied bed, what is important for the nurse to do?
- A. keep the bed in the low position.
- B. use a bath blanket or top sheet for warmth and privacy
- C. constantly keep side rails raised on both sides.
- D. move back and forth from one side to the other when adjusting the linens.
Correct answer: B
Rationale: When making an occupied bed, using a bath blanket or top sheet is important as it keeps the client warm and provides privacy, ensuring their comfort and dignity. Keeping the bed in the low position is crucial for the safety of the client, preventing falls and injuries. Constantly keeping side rails raised on both sides is unnecessary and may restrict the client's movement unnecessarily. Moving back and forth from one side to the other when adjusting the linens is inefficient and disrupts the workflow; it is more effective to work systematically from one side to the other to ensure proper bed-making.
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