NCLEX-PN TEST BANK

Safe and Effective Care Environment Nclex PN Questions

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: Inform the client that ear pain may occur and is normal.
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.

Nonpharmacological pain management involves all of the following except:

  • A. hypnosis alone.
  • B. psychological care, including support groups.
  • C. physical and psychological modalities.
  • D. pain-reducing drugs only.

Correct Answer: pain-reducing drugs only.
Rationale: Nonpharmacological pain management encompasses various strategies like hypnosis, psychological care, and physical and psychological modalities. The correct answer is 'pain-reducing drugs only' because nonpharmacological approaches do not solely rely on medications for pain management. Options A, B, and C are all valid components of nonpharmacological pain management. Hypnosis can help manage pain, psychological care including support groups can provide emotional support and coping strategies, and physical and psychological modalities encompass a wide range of interventions beyond just medication.

Which of the following is responsible for laws mandating the reporting of certain infections and diseases?

  • A. Centers for Disease Control and Prevention (CDC)
  • B. individual state laws
  • C. National Institutes of Health (NIH)
  • D. Health and Human Services (HHS)

Correct Answer: individual state laws
Rationale: Individual state laws mandate the reporting of infectious diseases. The list of reportable diseases varies from state to state and is overseen by state health departments. While the CDC plays a significant role in disease surveillance, reporting infectious diseases is primarily governed by individual state laws. The CDC's role is to provide support, guidance, and expertise to state health departments. The National Institutes of Health (NIH) primarily focus on biomedical and health-related research, not on mandating disease reporting. Health and Human Services (HHS) is a federal department that oversees various agencies, but the responsibility for mandating disease reporting lies with individual states.

Mrs. Peterson complains of difficulty falling asleep, awakening earlier than desired, and not feeling rested. She attributes these problems to leg pain that is secondary to her arthritis. What is the most appropriate nursing diagnosis for her?

  • A. Sleep Pattern Disturbances (related to chronic leg pain)
  • B. Fatigue (related to leg pain)
  • C. Knowledge Deficit (regarding sleep hygiene measures)
  • D. Sleep Pattern Disturbances (related to chronic leg pain)

Correct Answer: Sleep Pattern Disturbances (related to chronic leg pain)
Rationale: The most appropriate nursing diagnosis for Mrs. Peterson is 'Sleep Pattern Disturbances (related to chronic leg pain).' Mrs. Peterson's sleep issues are directly linked to her chronic leg pain, which is a result of her arthritis. This nursing diagnosis addresses the primary cause of her sleep disturbances and allows for interventions that focus on managing the pain to improve her sleep. Choices A, B, and C are incorrect. Choice A correctly identifies the relationship between sleep disturbances and chronic leg pain, addressing the root cause. Choice B is incorrect as it only focuses on fatigue and does not encompass the broader sleep issues. Choice C is not relevant as there is no indication that Mrs. Peterson lacks knowledge about sleep hygiene measures.

How far should the enema tube be inserted for a client to have a flatus-reducing enema?

  • A. 4 inches.
  • B. 6 inches.
  • C. 2 inches.
  • D. 8 inches.

Correct Answer: 4 inches.
Rationale: The correct answer is to insert the enema tube 4 inches. Enema tubing must be passed beyond the internal sphincter, which is typically around 4 inches in an adult. Inserting the tube only 2 inches is not far enough to reach this point. On the other hand, inserting the tube 6 or 8 inches is too far and might cause trauma to the bowel, which is unnecessary for a flatus-reducing enema. Therefore, the correct insertion depth of the enema tube is crucial to ensure effectiveness and safety in providing the intended treatment.

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