when making an occupied bed it is important for the nurse to

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. Why might breast implants interfere with mammography?

A. They might cause additional discomfort.
B. They are contraindications to mammography.
C. They are likely to be dislodged.
D. They might prevent detection of masses.

Correct answer: D

Rationale: Breast implants can interfere with mammography by potentially preventing the detection of masses. The presence of implants can obscure a clear view of breast tissue, making it difficult to identify abnormalities such as masses that may indicate breast cancer. Choices A, B, and C are incorrect because discomfort, contraindications, and dislodgment are not primary reasons why breast implants interfere with mammography. The main concern is the impedance of detecting abnormalities accurately due to the implants.

3. Which statement about clinical pathways is inaccurate?

A. They require daily updates.
B. They illustrate the expected client response to their diagnosis.
C. The objective is improvement or discharge from the facility.
D. They are evidence-based.

Correct answer: A

Rationale: The correct answer is that clinical pathways do not necessarily require daily updates. Clinical pathways can be customized to be updated daily, weekly, or at other intervals based on patient needs and facility protocols. Choice A is inaccurate as daily updates are not always mandatory for clinical pathways. Choices B, C, and D are accurate features of clinical pathways: they depict the expected client response to the diagnosis, aim for improvement or discharge, and are grounded in evidence-based practices to ensure optimal care.

4. Which of the following clients would be most appropriate for an LPN to assign to a nursing assistant?

A. an 18-year-old client with a femur fracture who is just returning to the floor from the recovery unit
B. an 84-year-old client 2 days post-op after knee replacement surgery who needs help ambulating
C. a 35-year-old client who is suffering from an acute asthma attack
D. a 20-year-old client with Cystic Fibrosis who needs an early morning sputum sample collection

Correct answer: D

Rationale: Collecting sputum samples on stable clients is within the scope of practice for an LPN. This task does not require immediate intervention or assessment by an RN or medical provider. An RN should perform the initial assessment on any client immediately post-op as it requires a higher level of assessment and monitoring. A client suffering from an acute asthma attack should be attended to by an RN or medical provider due to the potential severity and need for prompt intervention. Assigning a medically stable client who needs help ambulating to a nursing assistant is appropriate as it falls within their scope of practice and allows the LPN to focus on tasks that require their expertise.

5. All of the following tasks could be delegated to a nursing assistant or unlicensed assistive personnel (UAP) except:

A. monitoring intravenous infusion
B. assisting a client to the bathroom
C. offering fluid intake every 1-2 hours
D. monitoring/recording the amount of fluid taken

Correct answer: A

Rationale: Monitoring an intravenous infusion involves assessing for complications, adjusting the flow rate, and monitoring the client's response, which requires the knowledge and skills of a licensed nurse (RN or LPN). Tasks that can be delegated to nursing assistants or unlicensed assistive personnel include assisting a client to the bathroom, offering fluids, and recording fluid intake. These activities are within the scope of practice for UAPs as they do not involve the specialized knowledge and training needed for intravenous infusion monitoring.