NCLEX-PN
Safe and Effective Care Environment Nclex PN Questions
1. Common problems for supervisors include all of the following except:
- A. the supervisor facilitates development of staff members
- B. the supervisor micromanages staff members
- C. the supervisor wants to control the style in which a staff member correctly performs a task
- D. the supervisor does not delegate
Correct answer: A
Rationale: Common problems for supervisors include micromanaging staff members, wanting to control the style in which a staff member performs a task, and not delegating tasks effectively. These behaviors can hinder team building and overall effectiveness. Facilitating the development of staff members, on the other hand, is a positive attribute for a supervisor as it helps in nurturing the skills and growth of the team members. Therefore, the correct answer is 'the supervisor facilitates development of staff members' as this is not a common problem but a desirable quality in a supervisor.
2. Which of the following provides the framework for confidentiality and the client's right to privacy?
- A. Health Insurance Portability and Accountability Act
- B. CDC Surveillance Programs
- C. American Nurses Association Code of Ethics
- D. Durable Power of Attorney for Health Care
Correct answer: A
Rationale: The correct answer is the Health Insurance Portability and Accountability Act (HIPAA). HIPAA is the federal statute that outlines client confidentiality and the client's right to privacy. It establishes national standards to protect individuals' medical records and personal health information. The American Nurses Association Code of Ethics emphasizes principles of nursing ethics but does not serve as a legal framework for confidentiality and privacy. CDC Surveillance Programs focus on disease surveillance and control at a public health level and are not directly related to individual client privacy. The durable power of attorney for health care pertains to granting legal decision-making authority to another individual in healthcare matters, rather than addressing confidentiality and privacy rights.
3. An advance directive is written and notarized according to law in the state of Colorado. This document is legal and binding:
- A. internationally.
- B. in the state of Colorado only.
- C. in the continental United States.
- D. in the county of origination only.
Correct answer: B
Rationale: The correct answer is 'in the state of Colorado only.' Advance directive protocols and documents are specific to each state's laws and regulations. Choice A is incorrect as advance directives are not universally recognized internationally. Choice C is incorrect as the legal validity of an advance directive is limited to the state in which it was created. Choice D is incorrect as the legal reach of an advance directive typically extends throughout the state of origination, not just the county.
4. A nurse provides instructions to a mother about crib safety for her infant. Which statement by the mother indicates a need for further instructions?
- A. ''Wood surfaces on the crib need to be free of splinters and cracks.''
- B. ''I need to keep large toys out of the crib.''
- C. ''The distance between the slats needs to be no more than 4 inches wide to prevent entrapment of my infant's head or body.''
- D. ''The drop side needs to be impossible for my infant to release.''
Correct answer: C
Rationale: The correct answer is, ''The distance between the slats needs to be no more than 4 inches wide to prevent entrapment of my infant's head or body.'' This statement indicates a need for further instructions as the distance between the slats should be no more than 2? inches to prevent entrapment of the infant's head and body, not 4 inches. Allowing a larger gap can pose a risk of entrapment or injury to the infant. Keeping large toys out of the crib is essential to prevent the infant from using them to climb out, which could result in serious injuries. Ensuring the drop side of the crib is impossible for the infant to release is crucial to prevent falls and injuries. Additionally, maintaining wood surfaces on the crib free of splinters, cracks, and lead-based paint is vital for the infant's safety and well-being.
5. When a client is having a seizure and their blood oxygen saturation drops from 92% to 82%, what should the nurse do first?
- A. Open the airway.
- B. Administer oxygen.
- C. Suction the client.
- D. Check for breathing.
Correct answer: A
Rationale: When a client is experiencing a seizure and their blood oxygen saturation drops, the priority action for the nurse is to open the airway. Ensuring a clear airway is essential to maintain oxygenation during a seizure episode. Administering oxygen may be necessary but is secondary to ensuring a patent airway. Suctioning the client should only be done if there is an airway obstruction. Checking for breathing is important, but opening the airway takes precedence to support ventilation and oxygenation.
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