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. Quality is defined as a combination of all of the following except:
- A. conforming to standards.
- B. performing at the minimally acceptable level.
- C. meeting or exceeding customer requirements.
- D. exceeding customer expectations.
Correct answer: B
Rationale: Quality in any context is about meeting or exceeding customer requirements and exceeding customer expectations. It also involves conforming to standards to ensure consistency and reliability. Merely performing at the minimally acceptable level does not encompass the essence of quality, as it sets the bar at the lowest level of acceptability rather than aiming for excellence or customer satisfaction. Therefore, the correct answer is 'performing at the minimally acceptable level,' as this choice falls short in capturing the comprehensive definition of quality.
3. When the healthcare provider is determining the appropriate size of a nasopharyngeal airway to insert, which body part should be measured on the client?
- A. corner of the mouth to tragus of the ear
- B. corner of the eye to top of the ear
- C. tip of the chin to the sternum
- D. tip of the nose to the earlobe
Correct answer: D
Rationale: A nasopharyngeal airway is measured from the tip of the nose to the earlobe. This measurement ensures that the airway is of the correct length to reach the nasopharynx without being too long or too short. Choices A, B, and C are incorrect as they do not provide the appropriate measurement for selecting the correct size of a nasopharyngeal airway. The distance from the corner of the mouth to the tragus of the ear (Choice A) is used to measure for an oropharyngeal airway, not a nasopharyngeal airway. Similarly, the other choices (B and C) do not correlate with the correct measurement of a nasopharyngeal airway.
4. The nurse notes that a healthcare provider has documented the following prescription in a client's record: Furosemide (Lasix) 40 mg stat once. What action should the nurse take?
- A. Administering the medication
- B. Drawing up the medication in a syringe
- C. Planning to have the nurse on the next shift administer the medication
- D. Contacting the healthcare provider
Correct answer: D
Rationale: The correct action for the nurse to take in this situation is to contact the healthcare provider. The prescription provided lacks crucial information such as the route of administration. Before administering any medication, the nurse must clarify any missing details with the provider, especially for a stat prescription that requires immediate administration. Drawing up or administering the medication without verifying the route of administration is unsafe and can lead to errors. Planning for the next shift nurse to administer the medication is not appropriate in this scenario as the stat order necessitates immediate action. Therefore, the best course of action is to contact the healthcare provider to obtain clarification on the prescription.
5. After securing the client's safety from a faulty electric bed, what should the nurse do next?
- A. Discuss the matter with the client's significant others.
- B. Document the incident in the client's record in detail.
- C. Notify the physician.
- D. Prepare an incident report.
Correct answer: D
Rationale: After ensuring the client's safety from the faulty electric bed, the nurse should prioritize preparing an incident report. This report documents the details of what happened and is crucial for quality improvement and risk management. Choice A, discussing the matter with the client's significant others, may be important in some cases but is not the immediate priority after a safety incident. Choice B, documenting the incident in the client's record, is necessary but should be preceded by preparing an incident report. Choice C, notifying the physician, is important but not as urgent as preparing the incident report to ensure timely reporting and investigation of the safety issue.
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