the lpn is assisting the client with an ng tube with activities of daily living which of these statements would indicate need for teaching reinforceme
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Nursing Elites

NCLEX-PN

Safe and Effective Care Environment Nclex PN Questions

1. The LPN is assisting the client with an NG tube with activities of daily living. Which of these statements would indicate a need for teaching reinforcement?

Correct answer: A

Rationale: The correct answer is, "Since I'm not eating or drinking by mouth, I do not need to brush my teeth as often."? This statement indicates a need for teaching reinforcement because even when an NG tube is in place, the client should still brush their teeth twice daily. Good oral hygiene is essential to reduce the risk of introducing bacteria that may cause an infection. Choice B is incorrect because remaining sitting up at a 45-degree angle or higher for 30 minutes after a feeding is a correct statement regarding NG tube care, promoting proper digestion and reducing the risk of aspiration. Choice C is also incorrect because cleaning around the tube with water and mild soap is an appropriate practice to maintain cleanliness and prevent infection. Choice D is incorrect because advising to avoid using Vaseline around the nostril and tube is a proper instruction to prevent skin breakdown, occlusion of the tube, and potential aspiration of Vaseline into the lungs.

2. Acyclovir (Zovirax) is the agent of choice for which of the following infections?

Correct answer: D

Rationale: Acyclovir is an antiviral medication specifically effective in treating herpes infections. It works by inhibiting the replication of the herpes virus, shortening the duration of the infection. While Acyclovir can be used in HIV and AIDS patients to treat opportunistic viral infections, it is not a primary drug for managing HIV or AIDS itself. Candida is a type of fungus, and infections caused by Candida are treated with antifungal medications, not antivirals like Acyclovir. Therefore, the correct answer is herpes.

3. Which statement about clinical pathways is inaccurate?

Correct answer: A

Rationale: The correct answer is that clinical pathways do not necessarily require daily updates. Clinical pathways can be customized to be updated daily, weekly, or at other intervals based on patient needs and facility protocols. Choice A is inaccurate as daily updates are not always mandatory for clinical pathways. Choices B, C, and D are accurate features of clinical pathways: they depict the expected client response to the diagnosis, aim for improvement or discharge, and are grounded in evidence-based practices to ensure optimal care.

4. What information does the healthcare provider remember regarding do-not-resuscitate (DNR) orders in this scenario?

Correct answer: A

Rationale: In a situation where a client has no family members and the client's wife is mentally incompetent, the healthcare provider may write a DNR order if it is deemed medically certain that resuscitation would be futile. A DNR order is a medical directive that instructs healthcare providers not to perform CPR if a patient's heart stops or if the patient stops breathing. Option A is correct because a DNR order can indeed be issued by a healthcare provider under certain circumstances, as it is a medical decision. Options B, C, and D are incorrect as they do not accurately reflect the concept of DNR orders and the decision-making process involved in such situations.

5. What intervention should the nurse take for a client who has sustained a hyphema?

Correct answer: B

Rationale: The correct intervention for a client who has sustained a hyphema is to keep them at bed rest, usually with the head of the bed raised. This positioning helps to reduce intraocular pressure and prevent further damage or rebleeding. Instructing the client to wear eye protectors in the future (Choice A) is not the immediate intervention required for a hyphema. Applying atropine eyedrops (Choice C) is not typically indicated for a hyphema. Applying an ice pack to the site of injury (Choice D) is not recommended for a hyphema as it can increase the risk of rebleeding. Therefore, the correct answer is to keep the client at bed rest.

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