NCLEX-PN
Safe and Effective Care Environment Nclex PN Questions
1. Which of the following statements from a client may indicate that they are at a higher risk for a fall?
- A. "I would like to get out of bed but would like to put on my non-skid socks first."?
- B. "Can you make sure the two bedrails are raised before leaving the room?"?
- C. "I think I'm ready to walk a longer distance with the cane today."?
- D. "I need to get out of bed to go to the bathroom now. I cannot find my glasses but cannot wait."?
Correct answer: D
Rationale: The correct answer is 'I need to get out of bed to go to the bathroom now. I cannot find my glasses but cannot wait.' This statement indicates that the client is in a hurry and unable to find their glasses, which could increase the risk of a fall due to impaired vision. Choice A about putting on non-skid socks shows the client's awareness of fall prevention, reducing the risk. Choice B demonstrates the client's request for bedrails to be raised, which is a safety measure, reducing the risk as well. Choice C suggests the client's readiness to walk a longer distance with a cane, indicating progress in mobility but not necessarily a higher fall risk.
2. The LPN is preparing to clean a client's PEG tube.The following tasks should the nurse perform EXCEPT?
- A. Gently remove crusty drainage from the site.
- B. Pull the tube in multiple directions to ensure it is secure.
- C. Thoroughly dry the skin around the tube site with a clean towel.
- D. Use mild soap to clean around the tube site.
Correct answer: B
Rationale: When cleaning a client's PEG tube, the nurse should perform tasks that focus on gentle cleaning and avoiding potential irritants. Choice A is correct as gently removing crusty drainage helps maintain hygiene. Choice C is important to prevent skin irritation and infection. Choice D is appropriate for cleaning the area. Choices B and D are incorrect. Choice B is incorrect because pulling the tube in multiple directions can lead to dislodgement or injury. Choice B is incorrect as talcum powder may irritate the stoma, and it is generally not recommended near PEG tubes.
3. Which of these clients should the LPN/LVN see first?
- A. a client with a newly placed NG tube who is complaining of pain around the face and a plugged nose
- B. a post-op prostatectomy client who complains of bladder spasms and blood in his foley bag
- C. a client in an arm cast who is 2 days post-op and reports feelings of numbness and tingling in her affected arm
- D. a client newly diagnosed with Hepatitis A who reports stomach pain and itchy skin
Correct answer: C
Rationale: Numbness and tingling hours or days after a cast is applied may indicate compartment syndrome and should be reported to a medical provider right away. This is a potential emergency situation that requires immediate attention to prevent complications. The other options present expected or typical symptoms related to their diagnosis, which do not require immediate intervention. Complaints related to a newly placed NG tube such as pain around the face and a plugged nose may require assessment and intervention but are not as urgent as potential compartment syndrome. Bladder spasms and blood in the foley bag post-prostatectomy are common postoperative issues that can be addressed after the client in the arm cast with potential compartment syndrome is seen. Stomach pain and itchy skin in a client with Hepatitis A are common symptoms of the condition and do not indicate an emergency situation.
4. The nurse teaching a client about hepatitis and its transmission should explain that one type of hepatitis does not produce a carrier state after its acute phase. Which type is it?
- A. hepatitis A
- B. hepatitis B
- C. hepatitis C
- D. hepatitis D
Correct answer: A
Rationale: The correct answer is hepatitis A. Hepatitis A does not produce a carrier state after its acute phase. It is transmitted via contaminated water or food through the oral-fecal route and is not blood-borne. Hepatitis B, choice B, can lead to a carrier state where the person remains infectious despite being asymptomatic. Hepatitis C, choice C, can also result in a chronic carrier state. Hepatitis D, choice D, is an incomplete virus that requires hepatitis B to replicate; it does not lead to a carrier state on its own.
5. A client with cancer is transported to the radiology department for a bone scan to determine whether the cancer has metastasized to bone. While the client is in the radiology department, the client's wife arrives for a visit and asks what test is being performed on the client. What should the nurse tell the wife?
- A. A bone scan is being performed.
- B. She can read the client's medical record to determine what the health care provider prescribed.
- C. The radiology department is not clear as to which test has been prescribed.
- D. She will have to discuss the prescribed test with the client.
Correct answer: D
Rationale: In healthcare, confidentiality is crucial. Without the client's consent, nurses cannot disclose confidential information to anyone else, even to family members. Therefore, the appropriate response is to inform the client's wife that she will have to discuss the test with the client directly. It is not appropriate to disclose sensitive medical information without the client's permission. Offering the wife to read the medical record is a violation of privacy and confidentiality. Indicating that the radiology department is unclear about the prescribed test is inaccurate and does not uphold confidentiality. Moreover, it is not the responsibility of another department to disclose medical information; it is the duty of the healthcare provider and the client to discuss such matters.
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