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

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?

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. Which of the following lab values is associated with a decreased risk of cardiovascular disease?

Correct answer: A

Rationale: The correct answer is high HDL cholesterol. High HDL cholesterol levels are associated with a decreased risk of cardiovascular disease because HDL helps remove LDL cholesterol from the arteries, reducing plaque buildup. Low HDL cholesterol (choice B) is actually associated with an increased risk of cardiovascular disease. Low total cholesterol (choice C) or low triglycerides (choice D) are not indicators of a decreased risk of cardiovascular disease; in fact, extremely low total cholesterol levels may indicate other health issues.

3. Which isolation procedure will be followed for secretions and blood?

Correct answer: B

Rationale: The correct answer is Standard Precautions. Standard precautions are taken in all situations for all clients and involve all body secretions except sweat. They are designed to reduce the rate of transmission of microbes from one host to another or one source to another. Respiratory Isolation (Choice A) is used for diseases transmitted by airborne particles, not secretions and blood. Contact Isolation (Choice C) is for clients known or suspected to be infected with microorganisms that can be transmitted by direct or indirect contact. Droplet Isolation (Choice D) is used for diseases transmitted by large respiratory droplets expelled during coughing, sneezing, talking, or procedures.

4. Upon first meeting, a new nurse manager makes eye contact, smiles, initiates conversation about the previous work experience of nurses, and encourages active participation by nurses in the dialogue. Her behavior is an example of:

Correct answer: D

Rationale: The correct answer is 'Assertiveness.' This nurse manager is demonstrating assertive behavior by confidently engaging with the nurses, showing interest in their work experience, and encouraging active participation. Aggressive behavior is forceful and dominating, while passive behavior is submissive and timid. Passive-aggressive behavior involves indirect manipulation or control, which is not demonstrated in this scenario.

5. A client with cancer is transported to the radiology department for a bone scan to determine whether the cancer has metastasized to bone. While the client is in the radiology department, the client's wife arrives for a visit and asks what test is being performed on the client. What should the nurse tell the wife?

Correct answer: D

Rationale: In healthcare, confidentiality is crucial. Without the client's consent, nurses cannot disclose confidential information to anyone else, even to family members. Therefore, the appropriate response is to inform the client's wife that she will have to discuss the test with the client directly. It is not appropriate to disclose sensitive medical information without the client's permission. Offering the wife to read the medical record is a violation of privacy and confidentiality. Indicating that the radiology department is unclear about the prescribed test is inaccurate and does not uphold confidentiality. Moreover, it is not the responsibility of another department to disclose medical information; it is the duty of the healthcare provider and the client to discuss such matters.

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