NCLEX-PN
Safe and Effective Care Environment Nclex PN Questions
1. The LPN is checking for residual before administering enteral feeding through a PEG tube. Which of these steps is incorrect?
- A. The LPN elevates the head of the bed by at least 30 degrees.
- B. If the residual is greater than 200mL, the LPN should not administer the enteral feeding.
- C. The LPN should discard the residual before administering the tube feeding.
- D. The residual pH level is tested to ensure appropriate placement.
Correct answer: C
Rationale: The incorrect step is choice C. The residual should be discarded before administering the tube feeding. Discarding the residual is essential to prevent contamination and ensure accurate measurement of the enteral feeding. Elevating the head of the bed by at least 30 degrees (choice A) is correct as it helps prevent aspiration during feeding. Testing the pH level of the residual (choice D) ensures proper placement of the tube. Withholding feeding if the residual is greater than 200mL (choice B) is crucial to prevent overfeeding, making this statement correct.
2. Which of the following statements indicates adequate dietary understanding in a client with constipation?
- A. "I should decrease my intake of fluids."?
- B. "I should decrease my level of activity."?
- C. "I should increase my intake of apples."?
- D. "I should increase my intake of milk."?
Correct answer: C
Rationale: The correct answer is, "I should increase my intake of apples."? This statement indicates adequate dietary understanding in a client with constipation because apples are a good source of fiber, which helps alleviate constipation. Adequate fiber intake is essential for promoting bowel regularity. Choices A and B are incorrect as decreasing fluids and activity level can worsen constipation. Insufficient fluid intake can lead to hard stools, exacerbating constipation. Decreasing activity can also slow down bowel movements. Choice D is incorrect because milk is not a high-fiber food and may not effectively address constipation. While milk can have a mild laxative effect on some individuals, it is not a primary solution for constipation, especially when compared to high-fiber foods like apples.
3. Which hormone in the urine is specifically indicative of pregnancy?
- A. estrogen
- B. progesterone
- C. testosterone
- D. human chorionic gonadotropin
Correct answer: D
Rationale: Human chorionic gonadotropin is the hormone specifically indicative of pregnancy as it is produced by the placenta after implantation. It can be detected in urine and blood samples to confirm pregnancy. Estrogen and progesterone play crucial roles in the menstrual cycle and pregnancy but are not specific indicators of pregnancy on their own. Testosterone is a hormone primarily associated with male reproductive functions and is not directly related to pregnancy, making it an incorrect choice in this context.
4. What should a client room environment include?
- A. a made bed, fresh water, thermostat regulation, and clean floors in all occupied client areas.
- B. a made bed, comfort and safety, a clutter-free area, hygiene articles nearby.
- C. accident prevention, comfort, a room (including furniture) that has been cleaned with chloroseptic wash, a bed that is made every other day.
- D. odor control (by spraying the room with deodorizers), closet storage of all client objects, a clean room. (Gloves should be worn when cleaning.)
Correct answer: B
Rationale: A client room environment should include a made bed to provide a sense of neatness and comfort, ensuring the client's safety at all times. It is important to maintain a clutter-free area to prevent accidents and promote a relaxing environment. Having hygiene articles nearby allows the client easy access to personal care items. Choice A is incorrect because while fresh water and thermostat regulation are important, they are not essential components of a client room environment. Choice C is incorrect as it emphasizes more on cleaning procedures rather than creating a comfortable and safe environment for the client. Choice D is incorrect as it emphasizes odor control and storage rather than the client's comfort and safety.
5. What is mammography used to detect?
- A. pain
- B. tumor
- C. edema
- D. epilepsy
Correct answer: B
Rationale: Mammography is a diagnostic imaging technique specifically designed to detect tumors, cysts, or other abnormalities in breast tissue. It is not used to detect pain, edema, or epilepsy. Pain is a symptom, not a condition that mammography can detect. Edema refers to swelling and is not detectable through mammography. Epilepsy is a neurological disorder, not a condition detected by mammography.
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