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. Which of the following client statements indicates adequate understanding of preparation for electroencephalography?

A. "I don't need to eat or drink after midnight."?
B. "I need to wash my hair before the test."?
C. "I need to remove metal jewelry."?
D. "I can't take aspirin before the test."?

Correct answer: B

Rationale: The correct statement is, 'I need to wash my hair before the test.' Washing the hair is necessary to remove hair products that could interfere with electrode attachment to the scalp. Restricting food or drink is not required, except for avoiding caffeinated beverages. Removing metal jewelry is unnecessary for an electroencephalography procedure. Aspirin does not need to be avoided before the test; medications like anticonvulsants, tranquilizers, barbiturates, and sedatives are the ones that might need to be held.

3. Hearing screening of prematurely born infants is an effective means of identifying disease and is an example of:

A. Primary prevention.
B. Secondary prevention.
C. Tertiary prevention.
D. Disability prevention.

Correct answer: B

Rationale: The correct answer is B: Secondary prevention. Hearing screening for prematurely born infants falls under secondary prevention, which aims to identify and treat a condition in its early stages to prevent further complications. Primary prevention (choice A) focuses on preventing the disease from occurring, while tertiary prevention (choice C) involves managing complications and preventing disability. Choice D, disability prevention, is not a recognized category of prevention. In this context, the screening helps in early identification of hearing loss, allowing for timely intervention to prevent further impairment or complications, aligning with the principles of secondary prevention.

4. 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: B

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.

5. The goals of palliative care include all of the following except:

A. giving clients with life-threatening illnesses the best quality of life possible.
B. taking care of the whole person"?body, mind, spirit, heart, and soul.
C. no interventions are needed because the client is near death.
D. supporting the needs of the family and client.

Correct answer: C

Rationale: The correct goal of palliative care is to provide comprehensive care that addresses the physical, emotional, social, and spiritual needs of the dying client until the end of life. Therefore, the statement 'no interventions are needed because the client is near death' is incorrect as interventions are still essential to ensure comfort and quality of life. Choices A, B, and D are all aligned with the goals of palliative care, focusing on improving the quality of life, providing holistic care, and supporting both the family and the client.