NCLEX-PN
Safe and Effective Care Environment Nclex PN Questions
1. A client expresses anxiety about having magnetic resonance imaging performed. Which of the following is an appropriate response by the nurse?
- A. "You can receive a sedative to help you relax during the test."?
- B. "There is absolutely nothing to worry about."?
- C. "There is no discomfort with this test, so don't be anxious."?
- D. "The test won't last long, so you can handle it."?
Correct answer: A
Rationale: The correct response acknowledges the client's anxiety and offers a practical solution to alleviate it, showing empathy and addressing the client's concerns. Offering a sedative to help relax during the test is a proactive approach to managing the client's anxiety. Choices B and C dismiss the client's feelings by invalidating their anxiety, which can further escalate their distress. Choice D downplays the client's feelings by implying they should not be worried, which does not effectively address the client's emotional state.
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: In the scenario described, where multiple passengers on an airliner experience sudden weakness and breathing difficulty simultaneously, the most likely cause is chemical exposure. This is because a sudden onset of similar symptoms in a group of individuals suggests a common environmental factor affecting them. Options A, C, and D are less likely as they do not explain a sudden onset of symptoms in multiple individuals simultaneously. Asian flu (Option A) is a viral infection and would not typically result in sudden symptoms in multiple individuals at the same time. Bacterial pneumonia (Option C) is a localized infection and not a probable cause for a sudden onset of symptoms in a group. An allergic reaction (Option D) would usually occur in individuals with specific allergies rather than affecting a group of passengers at the same time.
3. A nurse calls a health care provider to question a prescription written for a higher-than-normal dosage of morphine sulfate. The health care provider changes the prescription to a dosage within the normal range, and the nurse documents the new telephone prescription in accordance with the agency's guidelines in the client's record. Which other statement does the nurse document in the nursing notes?
- A. The health care provider made a mistake in the written prescription for morphine sulfate.
- B. An inaccurate dosage of morphine sulfate was prescribed and the health care provider was informed.
- C. The health care provider was contacted to correct a mistake in the dosage of morphine sulfate.
- D. The health care provider was contacted to clarify the prescription for morphine sulfate
Correct answer: D
Rationale: The nurse needs to document a factual, descriptive, and objective statement that does not include words indicating that an individual made a mistake or performed an incorrect action or procedure. If a health care provider's prescription must be questioned, the nurse should record that clarification regarding the prescription was sought. Therefore, the correct statement to document is that the health care provider was contacted to clarify the prescription for morphine sulfate. Choices A, B, and C imply errors or mistakes on the part of the health care provider, which is not the focus of the documentation in this scenario.
4. A graduate nurse hired to work in a medical unit of a hospital is attending an orientation session. The nurse educator, discussing care maps, asks the graduate nurse whether she understands how a care map is used. Which response indicates understanding?
- A. The care map outlines the day-to-day expected outcomes of care and the outcomes anticipated at discharge
- B. The care map is a plan that is used only by the nurse to provide client care
- C. The care map is a standard plan, rather than an individualized one, that is developed strictly by a nurse and used for a client with a particular diagnosis
- D. The care map is developed by a nurse and identifies nursing diagnoses
Correct answer: A
Rationale: The correct answer is A. A care map, also known as a critical pathway, outlines the day-to-day expected outcomes of care and the outcomes anticipated at discharge or the end of a treatment phase. It includes clinical assessments, treatments, dietary interventions, activity therapies, client education, and discharge planning. While it may identify nursing diagnoses, a care map is developed by all disciplines caring for the client type and is used by the interdisciplinary team, not just the nurse alone. Choice B is incorrect because a care map is not solely for the nurse but for the entire interdisciplinary team. Choice C is incorrect as care maps are individualized plans developed by the interdisciplinary team, not just by a nurse. Choice D is incorrect as a care map is not solely about nursing diagnoses but encompasses a comprehensive plan of care.
5. What is mammography used to detect?
- A. pain
- B. tumor
- C. edema
- D. epilepsy
Correct answer: B
Rationale: Mammography is a diagnostic imaging technique specifically designed to detect tumors, cysts, or other abnormalities in breast tissue. It is not used to detect pain, edema, or epilepsy. Pain is a symptom, not a condition that mammography can detect. Edema refers to swelling and is not detectable through mammography. Epilepsy is a neurological disorder, not a condition detected by mammography.
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