NCLEX-PN
Safe and Effective Care Environment Nclex PN Questions
1. 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.
2. When caring for clients with Buck’s Traction, the major areas of importance should be:
- A. nutrition, elimination, comfort, safety
- B. ROM exercises, transportation
- C. nutrition, elimination, comfort, safety
- D. elimination, safety, isotonic exercises
Correct answer: C
Rationale: When caring for clients with Buck’s Traction, the major areas of importance should be nutrition, elimination, comfort, and safety. Proper nutrition, including a diet high in protein with adequate fluids, is essential for healing and recovery. Elimination refers to maintaining regular bowel and bladder function. Comfort is crucial to ensure the patient's well-being while in traction, and safety measures should be followed to prevent complications. Choices A, B, and D are incorrect. ROM exercises are not typically a primary concern with Buck’s Traction, making choices A and B incorrect. Isotonic exercises are not specifically related to the care of a client in Buck's Traction, making choice D incorrect.
3. A client with dysphagia is ready to eat lunch. Which of these foods on the tray would be best to start with when assisting the client?
- A. diced fruit
- B. apple juice with a liquid thickener
- C. Jell-O�
- D. toast
Correct answer: B
Rationale: The correct choice is apple juice with a liquid thickener. A client with dysphagia is at risk for aspiration, so it is crucial to start with liquids and assess the client's ability to swallow before introducing solid foods. Using a liquid thickener with apple juice allows the healthcare provider to evaluate swallowing function. Jell-O�, although it melts into a clear liquid, should be avoided initially as it may not provide a clear assessment of swallowing ability. Diced fruit and toast are solid foods that should be introduced only after the client's swallowing ability with liquids has been assessed.
4. 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.
5. A client expresses anxiety about having magnetic resonance imaging performed. Which of the following is an appropriate response by the nurse?
- A. "You can receive a sedative to help you relax during the test."?
- B. "There is absolutely nothing to worry about."?
- C. "There is no discomfort with this test, so don't be anxious."?
- D. "The test won't last long, so you can handle it."?
Correct answer: A
Rationale: The correct response acknowledges the client's anxiety and offers a practical solution to alleviate it, showing empathy and addressing the client's concerns. Offering a sedative to help relax during the test is a proactive approach to managing the client's anxiety. Choices B and C dismiss the client's feelings by invalidating their anxiety, which can further escalate their distress. Choice D downplays the client's feelings by implying they should not be worried, which does not effectively address the client's emotional state.
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