during an emergency procedure is the surgical timeout a requirement

NCLEX-PN

Nclex PN Questions and Answers

1. During an emergency procedure, is the surgical timeout a requirement?

A. The surgical timeout should be performed by the surgical team unless it would cause a delay leading to injury or death.
B. No, the timeout is not necessary during an emergency procedure.
C. No, the surgical timeout is not required in emergency procedures.
D. Yes, the surgical timeout must be performed in all cases.

Correct answer: A

Rationale: During an emergency procedure, the surgical timeout should be performed unless doing so would cause a delay leading to injury or death. This is because the primary goal during an emergency is to swiftly address the critical situation. Choice B is incorrect as it implies that the timeout is not necessary, which is not accurate. Choice C is also incorrect as it suggests that the timeout is not required in emergency procedures, disregarding safety protocols. Choice D is incorrect as it wrongly states that the timeout must be performed in all cases without considering the potential risks associated with delays during emergencies.

2. A client with an ileus is placed on intestinal tube suction. Which of the following electrolytes is lost with intestinal suction?

A. calcium
B. magnesium
C. potassium
D. sodium chloride

Correct answer: D

Rationale: When a client with an ileus is placed on intestinal tube suction, the primary electrolyte lost is sodium chloride. Duodenal intestinal fluid contains potassium (K+), sodium (Na+), and bicarbonate. Suctioning is done to remove excess fluids, leading to a decrease in the client's sodium chloride levels. Therefore, options A, B, and C are incorrect as calcium, magnesium, and potassium are not the primary electrolytes lost during intestinal suction in a client with an ileus.

3. How should the LPN document pain for a non-verbal client using the FLACC pain scale with these findings?

A. 1
B. 4
C. 3
D. 2

Correct answer: B

Rationale: The correct answer is B: '4'. The FLACC pain scale assesses pain in non-verbal patients based on five categories: Face, Legs, Activity, Cry, and Consolability. In this case, the client exhibits occasional grimacing (1 point), relaxed legs (0 points), squirming (1 point), moans and whimpers (1 point), and is distractible (1 point). Adding these points together results in a total pain score of 4. Therefore, the LPN should document a pain score of 4 for this non-verbal client. Choices A, C, and D are incorrect as they do not accurately reflect the total pain score based on the given findings.

4. How should an infant be secured in a car?

A. To hold the infant while sitting in the middle of the back seat of the car
B. To place the infant in the front seat in a rear-facing infant safety seat if the car has passenger-side air bags
C. To place the infant in a booster seat in the front seat with the shoulder and lap belts secured around the infant
D. To secure the infant in the middle of the back seat in a rear-facing infant safety seat

Correct answer: D

Rationale: The recommended way to secure an infant in a car is to place them in the middle of the back seat in a rear-facing infant safety seat. Option A is incorrect because infants should never be held while in a moving vehicle due to safety concerns. Option B is incorrect because placing an infant in the front seat with a rear-facing safety seat can be risky if the car has passenger-side airbags. Option C is incorrect as booster seats are not suitable for infants. Therefore, the correct choice is to secure the infant in the middle of the back seat in a rear-facing infant safety seat.

5. 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.