to remove hard contact lenses from an unresponsive client the nurse should

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: Ensure that the lens is centered on the cornea before gently manipulating the lids to release the lens

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. What is involved in client education by the nurse?

A. Telling the client everything about their disease, what will happen in the course of the disease, and the outcome.
B. Giving information to the client that is accurate and understandable.
C. Informing the client that the pain they experience might not be real.
D. Administering medication to the client when they experience pain.

Correct answer: Giving information to the client that is accurate and understandable.

Rationale: Client education by the nurse involves providing accurate and understandable information to the client. It is essential to offer relevant details without overwhelming them, making choice B the correct answer. Choice A is incorrect because providing excessive details can confuse the client rather than empower them with necessary knowledge. Choice C is incorrect as it is not the role of the nurse to question the reality of a client's pain; instead, they should address and manage the pain effectively. Choice D is incorrect as client education focuses on providing information and empowering clients with knowledge, not just administering medication.

3. The LPN needs to delegate a task to the nurse aide who is new to the unit. Which of these is the best option for the nurse to choose in proceeding?

A. Delegate the task to the nurse aide, confirm understanding, and follow up to ensure the task was safely and correctly done.
B. Delegate the task to the nurse aide, watch them perform the task without them seeing you, and follow up to ensure the task was done safely and accurately.
C. Delegate the task to the nurse aide, supervise if needed, and check in after the task to see if help is needed.
D. Delegate the task to the nurse aide, ensure understanding of the task, and supervise the task being performed.

Correct answer: Delegate the task to the nurse aide, watch them perform the task without them seeing you, and follow up to ensure the task was done safely and accurately.

Rationale: Delegation is transferring responsibility for a task but sharing its accountability. It is the delegator’s responsibility to ensure that the delegatee understands the task before it is performed and to follow up afterward to ensure it was completed correctly and safely. Option B is the best choice because it allows the nurse to observe the nurse aide performing the task without pressure, which can provide insights into the aide's abilities and understanding. This method also allows for immediate feedback and correction if needed. Choice A is incorrect because confirming understanding alone may not provide a complete picture of the aide's competence in performing the task. Choice C is incorrect as it suggests supervising only if needed, which may not provide adequate oversight for a new nurse aide. Choice D is incorrect because supervising the task being performed does not allow for an objective assessment of the aide's abilities and understanding.

4. A discharge planning nurse is making arrangements for a client with an epidural catheter for continuous infusion of opioids to be placed in a long-term care facility. The family prefers a facility in its neighborhood to facilitate visiting. The neighborhood facility has never cared for a client with this type of need. What is the most appropriate action by the discharge planning nurse?

A. Arrange for immediate in-services for the long-term care facility staff on pain management using epidural catheters.
B. Explain the situation to the client and family and seek another long-term care facility for discharge from the hospital.
C. Encourage the family to hire private duty nurses skilled in epidural catheter pain management to allow the client to be transferred to the neighborhood facility.
D. None of the above

Correct answer: Explain the situation to the client and family and seek another long-term care facility for discharge from the hospital.

Rationale: In this scenario, the priority is the safety and well-being of the client. The neighborhood facility's lack of experience in caring for a client with an epidural catheter for continuous opioid infusion raises concerns about the quality of care they can provide. Therefore, the most appropriate action for the discharge planning nurse is to explain the situation to the client and family and seek another long-term care facility that can provide the necessary care. Option A, arranging for immediate in-services, may not be feasible or timely, considering the urgent need for appropriate care. Option C, encouraging the family to hire private duty nurses, does not ensure the facility's overall capability to manage the client's complex needs. Option D, 'None of the above,' is not the best choice as the client's safety should be the priority in this situation.

5. A case manager is reviewing the records of the clients in the nursing unit. Which note(s) in a client’s record indicate an unexpected outcome and the need for follow-up?

A. A client is performing their own colostomy irrigations.
B. A client with a central venous catheter has a temperature of 100.6°F.
C. A client who has just undergone surgery has a urine output of more than 30 mL/hr.
D. A client with a new diagnosis of diabetes mellitus is self-administering insulin.

Correct answer: A client with a central venous catheter has a temperature of 100.6°F.

Rationale: A case manager is a healthcare professional responsible for coordinating a client's care from admission through and after discharge. They evaluate and update the plan of care as needed, monitoring for unexpected outcomes and providing follow-up. A temperature of 100.6°F in a client with a central venous catheter is an unexpected outcome that requires follow-up due to the potential indication of an infection. Choices A, C, and D describe expected outcomes and appropriate self-care management. The client self-irrigating their colostomy, a post-surgical client having adequate urine output, and a newly diagnosed diabetic self-administering insulin are all positive indicators of self-care and expected outcomes, not requiring immediate follow-up.