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. A client with a spinal cord injury is preparing to return home from the rehabilitation unit. Which of the following statements by a family member indicates a need for further teaching regarding autonomic dysreflexia?

Correct answer: D

Rationale: If the client develops signs or symptoms of autonomic dysreflexia, they need to be addressed immediately. If the family member is not able to relieve them, a healthcare provider needs to be notified immediately. The statement 'I should observe whether symptoms worsen' indicates a passive approach and does not address the urgency of the situation. Choices A, B, and C are correct as they involve active measures to address autonomic dysreflexia, such as raising the client to a sitting position, checking for a fecal impaction, and looking for a kink in the urinary catheter tubing.

3. Why might breast implants interfere with mammography?

Correct answer: D

Rationale: Breast implants can interfere with mammography by potentially preventing the detection of masses. The presence of implants can obscure a clear view of breast tissue, making it difficult to identify abnormalities such as masses that may indicate breast cancer. Choices A, B, and C are incorrect because discomfort, contraindications, and dislodgment are not primary reasons why breast implants interfere with mammography. The main concern is the impedance of detecting abnormalities accurately due to the implants.

4. Common problems for supervisors include all of the following except:

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.

5. A client scheduled for a left mastectomy and axillary lymph node dissection is wearing a wedding band on her left ring finger. The nurse should take which action?

Correct answer: C

Rationale: In most situations, a wedding band may be taped in place and worn during a surgical procedure. However, if there is a possibility that the client will experience swelling of the hand or fingers, the wedding band should be removed. On admission to a healthcare facility, the client is usually asked to sign a form that releases the agency from responsibility if a client's valuables are lost. After a mastectomy with axillary lymph node dissection, the client is at risk for lymphedema, which can result in swelling of the arm and hand on the affected side. Therefore, the appropriate nursing action is to ask the client to remove the wedding band and explain why. This ensures the client's safety and prevents potential complications. Option A is incorrect because taping the wedding band may not be sufficient if swelling occurs. Option B is incorrect as it does not address the immediate need to remove the wedding band. Option D is incorrect because it fails to provide the client with the necessary information about the potential risks of wearing the wedding band during surgery.

Similar Questions

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