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. Several passengers aboard an airliner suddenly become weak and suffer breathing difficulty. The diagnosis is likely to be:
- A. Outbreak of Asian flu.
- B. Chemical exposure.
- C. Bacterial pneumonia.
- D. Allergic reaction.
Correct answer: B
Rationale: The most likely cause of groups of individuals suddenly experiencing similar signs of illness all at once is a chemical exposure. In this scenario, considering the sudden onset of symptoms in multiple passengers on an airliner, the symptoms are more indicative of a chemical exposure rather than Asian flu, bacterial pneumonia, or an allergic reaction. Asian flu, bacterial pneumonia, and allergic reactions do not typically manifest in a way that would affect a group of individuals simultaneously. Therefore, the correct diagnosis in this case is likely to be a chemical exposure.
3. What is distraction therapy?
- A. Focusing one's attention on stimuli other than pain.
- B. Cognitive reappraisal.
- C. The replacement of positive images of pain with other images.
- D. The use of medication and meditation.
Correct answer: A
Rationale: Distraction therapy involves directing attention away from pain towards positive stimuli, which can help reduce the perception of pain. Choice A is the correct answer as it accurately defines distraction therapy. Cognitive reappraisal (Choice B) involves changing the way one thinks about a situation to alter its emotional impact, which is different from distraction therapy. Choice C is incorrect because distraction therapy does not involve replacing images of pain with other images, but rather focusing on something unrelated. Choice D is incorrect as distraction therapy does not necessarily involve medication or meditation, but rather the redirection of attention.
4. A nursing student is assigned to care for a client who requires a total bed bath. When the student explains to the client that she is going to gather supplies to administer the bath, the client states, 'I don't want a bath. I've been up all night, and I'm clean enough.' The student reports the client's refusal to the nurse. Which action by the nurse is appropriate?
- A. Telling the nursing student to persuade the client to have a bath so that the evening shift staff will not have to do it
- B. Telling the nursing student to allow the client to rest
- C. Telling the client that the refusal of care will be informed to the health care provider
- D. Telling the nursing student to give the client the bath anyway
Correct answer: B
Rationale: The client has the right to refuse a treatment or procedure, and if the client does refuse, the nurse must respect the client's decision. Therefore, the nurse would allow the client to rest. Persuading the client to have a bath and giving the bath anyway are both inappropriate as they violate the client's rights. Informing the health care provider of the refusal of care can be discussed with the client if needed, but the immediate action should be to respect the client's wishes and allow them to rest.
5. Signs of internal bleeding include all of the following except:
- A. painful or swollen extremities
- B. a tender, rigid abdomen
- C. vomiting bile
- D. bruising
Correct answer: C
Rationale: Vomiting bile is not typically a sign of internal bleeding but is more commonly associated with issues in the gastrointestinal tract. Signs of internal bleeding include painful or swollen extremities, a tender, rigid abdomen, and bruising. Painful or swollen extremities can indicate bleeding from an extremity injury, a tender, rigid abdomen can signal abdominal bleeding, and bruising can result from blood vessel damage. Therefore, the correct answer is 'C: vomiting bile,' as it is not a typical sign of internal bleeding.
Similar Questions
Access More Features
NCLEX PN Basic
$69.99/ 30 days
- 5,000 Questions with answers
- Comprehensive NCLEX coverage
- 30 days access
NCLEX PN Premium
$149.99/ 90 days
- 5,000 Questions with answers
- Comprehensive NCLEX coverage
- 30 days access