the lpn is placing a foley in a female client place the following steps in the appropriate order a prepare the sterile field b separate labia with non
Logo

Nursing Elites

NCLEX-PN

Safe and Effective Care Environment Nclex PN Questions

1. When placing a Foley catheter in a female client, what is the correct order of steps?

Correct answer: D

Rationale: The correct order for placing a Foley catheter in a female client is as follows: E. Place the client in a supine position with flexed knees, A. Prepare the sterile field, F. Place lubricant on the catheter, B. Separate labia with the non-dominant hand, C. Clean the urinary meatus using cleansing solutions and forceps, G. Place the catheter in the meatus with the dominant (sterile) hand, and D. Inflate the catheter balloon. This sequence ensures proper hygiene, patient comfort, and reduces the risk of infection. Incorrect sequences could compromise sterility, cause discomfort, and increase the risk of infection. Therefore, the correct answer is E, A, F, B, C, G, D.

2. Which of these would be the most appropriate way to document a client's refusal of medication?

Correct answer: C

Rationale: The most appropriate way to document a client's refusal of medication should include details such as the medication, the client's statement of refusal, and the review of potential risks. Choice C accurately captures all these essential elements, making it the correct answer. Choice A lacks details about the client's refusal and the review of risks. Choice B includes unnecessary emotional descriptions and a plan of action that might not be appropriate. Choice D uses abbreviations that may not be universally understood, lacks proper punctuation, and also does not provide a detailed account of the refusal and the review of risks.

3. While observing a client using crutches for a leg injury, which action would indicate a need for more education by the LPN?

Correct answer: B

Rationale: The correct answer is B. Resting the axilla on the top padding can cause nerve damage; instead, the client should place the top padding 1-2 inches below the axilla with a firm grip on the handles for proper support and stability while using crutches. Having a slight bend in the elbow when using the handles (choice C) is a correct technique to ensure proper weight distribution. Leading with the uninjured leg when going down the stairs (choice D) is the correct way to maintain balance and prevent further injury to the injured leg. Therefore, choice B indicates a need for more education to prevent potential nerve damage and ensure safe crutch use.

4. A nurse who works in a medical care unit is told that she must float to the intensive care unit because of a short-staffing problem on that unit. The nurse reports to the unit and is assigned to three clients. The nurse is angry with the assignment because she believes that the assignment is more difficult than the assignment delegated to other nurses on the unit and because the intensive care unit nurses are each assigned only one client. The nurse should most appropriately take which action?

Correct answer: D

Rationale: In this scenario, the nurse feeling that the assignment is more difficult than what other nurses received should approach the nurse manager of the intensive care unit to discuss the assignment. By doing so, the nurse can seek clarification on the rationale for the assignment or confirm if it is genuinely more challenging. Refusing the assignment is not appropriate as it could impact patient care. Returning to the medical care unit would be considered client abandonment and does not directly address the conflict at hand. Instructing the nurse manager to involve the nursing supervisor is an aggressive approach that does not directly resolve the issue.

5. A director of nursing at a long-term care center has announced a change to computerized documentation of nursing care. A certified nursing assistant (CNA) on the team, resistant to the change, is not taking an active part in facilitating the implementation of the new procedure. Which strategy would be the best approach to dealing with the conflict?

Correct answer: A

Rationale: The best approach to dealing with resistance to change is through open communication and understanding. Meeting with the CNA and encouraging him to express his feelings regarding the change allows for a constructive dialogue where issues can be addressed, and alternative solutions can be explored. Ignoring the resistance does not help in resolving the conflict and may lead to further issues. Telling the CNA that a licensed practical nurse (LPN) will perform all computer documentation while he documents intake and output and vital signs does not address the underlying concerns of the CNA and may create more resistance. Threatening the CNA with noncompliance consequences may escalate the resistance and create a negative work environment.

Similar Questions

A client is on a clear liquid diet. She drinks half of a 12-ounce juice, 4 ounces of soup, and has a 6-ounce JELLO�. How many milliliters of fluid did the patient ingest?
A new nurse employed at a community hospital is reading the organization's mission statement. The new nurse understands that this statement is written for which purpose?
An advance directive is written and notarized according to law in the state of Colorado. This document is legal and binding:
The LPN is checking for residual before administering enteral feeding through a PEG tube. Which of these steps is incorrect?
The ICU nurse caring for a client who has just been declared brain dead can expect to find evidence of the client's wishes regarding organ donation:

Access More Features

NCLEX PN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access

NCLEX PN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access

Other Courses