NCLEX-PN
Safe and Effective Care Environment Nclex PN Questions
1. 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: bleeding problems.
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.
2. A nursing student is assigned to care for a client who requires a total bed bath. When the student explains to the client that she is going to gather supplies to administer the bath, the client states, 'I don’t want a bath. I’ve been up all night, and I’m clean enough.' The student reports the client’s refusal to the nurse. Which action by the nurse is appropriate?
- A. Telling the nursing student to persuade the client to have a bath so that the evening shift staff will not have to do it
- B. Telling the nursing student to allow the client to rest
- C. Telling the client that the refusal of care will be informed to the health care provider
- D. Telling the nursing student to give the client the bath anyway
Correct answer: Telling the nursing student to allow the client to rest
Rationale: The client has the right to refuse a treatment or procedure, and if the client does refuse, the nurse must respect the client’s decision. Therefore, the nurse would allow the client to rest. Persuading the client to have a bath and giving the bath anyway are both inappropriate as they violate the client's rights. Informing the health care provider of the refusal of care can be discussed with the client if needed, but the immediate action should be to respect the client's wishes and allow them to rest.
3. A Hispanic client brings her father to the clinic because he is becoming more forgetful. He is diagnosed with Alzheimer’s disease. The woman tells the nurse that she wants to try ginkgo biloba for her father before using prescription medications. Which of the following is an appropriate response by the nurse?
- A. “It is wiser to start with a prescription.”
- B. “That herb may not be effective for your father.”
- C. “You can’t expect an herb to cure Alzheimer’s.”
- D. “I will let the physician know of your wishes.”
Correct answer: “I will let the physician know of your wishes.”
Rationale: The appropriate response is to acknowledge the client's wishes and communicate them to the physician for consideration. It is important to be culturally sensitive and respect the client's preferences. Ginkgo biloba has shown some benefits in treating dementia, so it is essential to involve the healthcare provider in the decision-making process. Choices A, B, and C are dismissive and fail to consider the client's perspective and cultural beliefs. It is crucial for healthcare professionals to engage in open communication and collaboration with clients to provide patient-centered care.
4. Which of the following is not one of the four categories related to client care plans?
- A. privacy
- B. evaluation
- C. diagnosis
- D. outcome
Correct answer: privacy
Rationale: The four categories related to client care plans are diagnosis, intervention, outcome, and evaluation. Privacy is not typically considered a distinct category in client care plans, as it is more of a fundamental aspect that underlies all care provided to clients. Choices B, C, and D are directly related to the components of client care plans, making them incorrect answers in this context.
5. An LPN is talking with a client scheduled to undergo a vasectomy in the next few minutes. He states, “I know I signed the form and all, but I’m not feeling so sure of this. It can be reversed pretty easily, right?” What is the LPN’s best response?
- A. “Yes, vasectomies can be reversed, but once you have it, you may regret it later.”
- B. “It’s normal to feel a little nervous before a procedure like this.”
- C. “It sounds like you have a few more questions you’d like answered. Let me grab the doctor quickly so he can answer them for you.”
- D. “It sounds like you might be a little nervous. Don’t worry, this is a pretty minor procedure, and the doctor doing it is the best we have. You’re in great hands.”
Correct answer: “It sounds like you have a few more questions you’d like answered. Let me grab the doctor quickly so he can answer them for you.”
Rationale: The best response for the LPN is to acknowledge the client's concerns and offer to provide more information. By offering to get the doctor to answer any additional questions, the LPN shows respect for the client's right to informed consent. Option A provides some information but dismisses the client's uncertainty and implies they won't regret the decision, which may not be the case. Option B acknowledges nervousness but doesn't directly address the client's request for more information. Option D attempts to reassure the client but fails to address the need for additional questions to be answered by the doctor.
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