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?
- A. E, A, F, B, C, G, D
- B. A, E, B, F, G, D, C
- C. A, E, F, B, C, G, D
- D. E, A, F, B, C, G, D
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. A nurse calls a health care provider to question a prescription written for a higher-than-normal dosage of morphine sulfate. The health care provider changes the prescription to a dosage within the normal range, and the nurse documents the new telephone prescription in accordance with the agency's guidelines in the client's record. Which other statement does the nurse document in the nursing notes?
- A. The health care provider made a mistake in the written prescription for morphine sulfate.
- B. An inaccurate dosage of morphine sulfate was prescribed and the health care provider was informed.
- C. The health care provider was contacted to correct a mistake in the dosage of morphine sulfate.
- D. The health care provider was contacted to clarify the prescription for morphine sulfate
Correct answer: D
Rationale: The nurse needs to document a factual, descriptive, and objective statement that does not include words indicating that an individual made a mistake or performed an incorrect action or procedure. If a health care provider's prescription must be questioned, the nurse should record that clarification regarding the prescription was sought. Therefore, the correct statement to document is that the health care provider was contacted to clarify the prescription for morphine sulfate. Choices A, B, and C imply errors or mistakes on the part of the health care provider, which is not the focus of the documentation in this scenario.
3. The nurse in the emergency room is admitting a client who has sustained a gunshot wound and will require immediate surgery. The client is unconscious and by themselves. Which of the following actions is most appropriate?
- A. Call the charge nurse and request that the facility's legal counsel provide a waiver for informed consent.
- B. Attempt to stabilize the client in the emergency room until they are conscious enough to provide informed consent.
- C. Try to locate the client's family to obtain informed consent before transporting the client to the operating room.
- D. Proceed with transporting the client to the operating room without obtaining informed consent.
Correct answer: D
Rationale: In emergency situations where a client is unconscious and requires immediate surgery to save their life, the priority is to proceed with necessary interventions without delay to ensure the best possible outcome. Obtaining informed consent is essential in healthcare, but in situations where a delay in treatment can be life-threatening, healthcare providers are ethically and legally permitted to proceed with treatment without consent. Attempting to stabilize the client until conscious enough to provide consent or trying to locate family members for consent would cause a dangerous delay in critical care. Therefore, the most appropriate action in this scenario is to transport the unconscious client to the operating room for immediate surgery.
4. When managing nausea related to Morphine epidural analgesia, the nurse should administer:
- A. Indomethacin
- B. Codeine
- C. Ibuprofen
- D. Compazine
Correct answer: D
Rationale: When managing nausea related to Morphine epidural analgesia, Compazine is the appropriate medication to administer. Compazine, also known as prochlorperazine, is commonly used to treat nausea and vomiting. It works by affecting certain chemicals in the brain that trigger nausea and vomiting. Choices A, B, and C are incorrect because Indomethacin, Codeine, and Ibuprofen are not typically used to manage nausea associated with Morphine epidural analgesia.
5. Which of the following clients would be most appropriate for an LPN to assign to a nursing assistant?
- A. an 18-year-old client with a femur fracture who is just returning to the floor from the recovery unit
- B. an 84-year-old client 2 days post-op after knee replacement surgery who needs help ambulating
- C. a 35-year-old client who is suffering from an acute asthma attack
- D. a 20-year-old client with Cystic Fibrosis who needs an early morning sputum sample collection
Correct answer: D
Rationale: Collecting sputum samples on stable clients is within the scope of practice for an LPN. This task does not require immediate intervention or assessment by an RN or medical provider. An RN should perform the initial assessment on any client immediately post-op as it requires a higher level of assessment and monitoring. A client suffering from an acute asthma attack should be attended to by an RN or medical provider due to the potential severity and need for prompt intervention. Assigning a medically stable client who needs help ambulating to a nursing assistant is appropriate as it falls within their scope of practice and allows the LPN to focus on tasks that require their expertise.
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