NCLEX-PN
Safe and Effective Care Environment Nclex PN Questions
1. When making an occupied bed, what is important for the nurse to do?
- A. keep the bed in the low position.
- B. use a bath blanket or top sheet for warmth and privacy
- C. constantly keep side rails raised on both sides.
- D. move back and forth from one side to the other when adjusting the linens.
Correct answer: B
Rationale: When making an occupied bed, using a bath blanket or top sheet is important as it keeps the client warm and provides privacy, ensuring their comfort and dignity. Keeping the bed in the low position is crucial for the safety of the client, preventing falls and injuries. Constantly keeping side rails raised on both sides is unnecessary and may restrict the client's movement unnecessarily. Moving back and forth from one side to the other when adjusting the linens is inefficient and disrupts the workflow; it is more effective to work systematically from one side to the other to ensure proper bed-making.
2. What is the correct instruction to give a client undergoing mammography?
- A. Do not use underarm deodorant.
- B. Wear comfortable clothing.
- C. Avoid caffeine prior to the procedure.
- D. Bring a list of current medications.
Correct answer: A
Rationale: The correct instruction for a client undergoing mammography is not to use underarm deodorant. Underarm deodorant can cause confusing shadows on the X-ray film, affecting the accuracy of the mammogram. Choices B, C, and D are incorrect. While wearing comfortable clothing is advisable, it is not the primary instruction for mammography. Avoiding caffeine and bringing a list of current medications are not specific instructions related to mammography preparation and are therefore not the correct answers.
3. All of the following are causes of vaginal bleeding in late pregnancy except:
- A. Placenta previa.
- B. Eclampsia.
- C. Abruptio placentae.
- D. Uterine rupture.
Correct answer: B
Rationale: The correct answer is B: Eclampsia. Eclampsia is a disorder of pregnancy characterized by hypertension, proteinuria, and edema. This condition can cause seizures and/or coma but does not typically present with vaginal bleeding. Choices A, C, and D are abnormal conditions that can cause bleeding, particularly in the third trimester. Placenta previa (choice A) is a condition where the placenta partially or completely covers the cervix, leading to vaginal bleeding. Abruptio placentae (choice C) is the premature separation of the placenta from the uterine wall, causing vaginal bleeding. Uterine rupture (choice D) is a serious obstetrical emergency where the uterus tears during pregnancy or childbirth, resulting in severe bleeding.
4. A nurse and a nursing assistant enter a client's room to provide care and find the client lying on the floor. Which action should the nurse take first?
- A. Ask the nursing assistant to complete an incident report
- B. Check the client's level of consciousness and vital signs
- C. Contact the unit secretary on the intercom and ask that the client's health care provider be called
- D. Ask the nursing assistant to assist in getting the client back to bed
Correct answer: B
Rationale: When a client sustains a fall, the nurse must first assess the client. The nurse should check the client's level of consciousness and vital signs to determine the severity of the situation and provide appropriate care promptly. This immediate assessment is crucial in ensuring the client's immediate needs are addressed. Asking the nursing assistant to complete an incident report (choice A) is not the priority as the client's condition needs immediate attention. Contacting the unit secretary to call the client's health care provider (choice C) can be done after the initial assessment has been completed. Asking the nursing assistant to assist in getting the client back to bed (choice D) should only be considered after ensuring the client is stable and safe to move.
5. Which of the following is an indication for electroencephalography?
- A. paralysis
- B. neuropathy
- C. seizure disorder
- D. myocardial infarction
Correct answer: C
Rationale: The correct answer is C: 'seizure disorder.' Electroencephalography is used to assess clients with seizure disorders by recording the brain's electrical activity. Seizure disorder is a primary indication for an EEG as it helps in diagnosing and managing seizure activity. Paralysis (choice A) is not typically an indication for an EEG as it relates to loss of muscle function rather than brain activity. Neuropathy (choice B) involves nerve damage and is not directly assessed by an EEG. Myocardial infarction (choice D) is related to heart issues and is not a condition that an EEG is used to diagnose.
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