NCLEX-PN
Safe and Effective Care Environment Nclex PN Questions
1. When the healthcare provider is determining the appropriate size of an oropharyngeal airway to insert, what part of a client's body should they measure?
- A. corner of the mouth to the tragus of the ear
- B. corner of the eye to the top of the ear
- C. tip of the chin to the sternum
- D. tip of the nose to the earlobe
Correct answer: A
Rationale: When selecting the correct size of an oropharyngeal airway, the healthcare provider should measure from the corner of the client's mouth to the tragus of the ear. This measurement ensures that the airway is the appropriate length to maintain a clear air passage for exchange. Measuring from the corner of the eye to the top of the ear (Choice B) is inaccurate and not a standard measurement for selecting the size of an oropharyngeal airway. Measuring from the tip of the chin to the sternum (Choice C) is irrelevant to determining the correct size of the airway. Similarly, measuring from the tip of the nose to the earlobe (Choice D) is also incorrect and does not provide the necessary measurement for selecting an oropharyngeal airway size.
2. The mother of a child who weighs 45 lb asks a nurse about car safety seats. The nurse tells the mother to place the child in which car safety seat?
- A. Car safety seat in the back seat in a face-forward position
- B. Booster seat with one of the car's seat belts placed over the child
- C. Booster seat in a rear-facing position in the front seat
- D. Car safety seat in a face-forward position in the front seat
Correct answer: B
Rationale: The correct answer is to place the child in a booster seat with one of the car's seat belts placed over the child. A child needs to remain in a car safety seat until he or she weighs 40 lb. Once the child has outgrown the car safety seat, a booster seat is used. Booster seats are designed to raise the child high enough so that the restraining straps are correctly positioned over the child's chest and pelvis, providing optimal safety. Placing a child in a booster seat in a rear-facing position in the front seat is incorrect as children should not be seated in the front seat due to potential airbag-related injuries. Additionally, car safety seats are used for children weighing less than 40 lb and are placed in the middle of the back seat in a rear-facing position for maximum protection.
3. When the nurse is determining the appropriate size of an oropharyngeal airway to insert, what part of a client's body should she measure?
- A. corner of the mouth to the tragus of the ear
- B. corner of the eye to the top of the ear
- C. tip of the chin to the sternum
- D. tip of the nose to the earlobe
Correct answer: B
Rationale: Correct! When sizing an oropharyngeal airway, the nurse should measure from the corner of the client's mouth to the tragus of the ear. This measurement ensures that the airway is the appropriate length to reach the pharynx without being too long or too short. Choices B, C, and D are incorrect as they do not provide the correct anatomical landmarks for determining the size of an oropharyngeal airway. Measuring from the corner of the mouth to the tragus of the ear is a standard method to ensure proper airway size and prevent complications during airway management.
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. Which of the following medications might cause upper-gastrointestinal (UGI) bleeding?
- A. Cardizem (diltiazem)
- B. Naprosyn (naproxen)
- C. Elavil (amitriptyline)
- D. Corgard (nadolol)
Correct answer: C
Rationale: Naprosyn (naproxen) is known to cause upper-gastrointestinal (UGI) bleeding due to its effects on the stomach lining. Naproxen is a nonsteroidal anti-inflammatory drug (NSAID) that can irritate the stomach and increase the risk of UGI bleeding. On the other hand, Cardizem (diltiazem), Elavil (amitriptyline), and Corgard (nadolol) are not typically associated with UGI bleeding. Cardizem is a calcium channel blocker used for hypertension and angina, Elavil is a tricyclic antidepressant, and Corgard is a beta-blocker used for hypertension.
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