the nurse uses prioritization to determine all the following except
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Nursing Elites

NCLEX-PN

Safe and Effective Care Environment Nclex PN Questions

1. The nurse uses prioritization to determine all of the following except:

Correct answer: C

Rationale: The correct answer is C: "treatment procedures." Prioritization in nursing involves determining the order of importance or urgency of tasks. Treatment procedures are standards of care that need to be followed as defined by the facility or nursing unit. They are not typically subject to prioritization but are mandatory based on established protocols. Time allotment for certain tasks, appropriate interventions, and the need for client education are all aspects that can be influenced by prioritization. For instance, prioritizing tasks helps in managing time effectively, selecting the most suitable interventions, and identifying the necessity for client education as part of the care plan.

2. 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.

3. A Roman Catholic client is preparing to have magnetic resonance imaging. He wants to wear his metal crucifix pendant while he is receiving the test. Which of the following is an appropriate response by the nurse?

Correct answer: C

Rationale: No metal objects may be worn while receiving magnetic resonance imaging due to safety risks involved with the strong magnet. The correct response by the nurse should prioritize the safety of the client. Allowing the client to wear the metal crucifix poses a risk of injury or interference with the imaging process. Option A is not appropriate as safety takes precedence over comfort in this situation. Option B is incorrect as it does not address the safety concerns associated with wearing metal objects during an MRI. Option D is also incorrect as it fails to acknowledge the safety issue involved and instead focuses solely on the importance to the client. It is important for the nurse to offer alternative forms of spiritual support that do not pose a risk during the MRI procedure.

4. Signs of internal bleeding include all of the following except:

Correct answer: C

Rationale: Vomiting bile is not typically a sign of internal bleeding but is more commonly associated with issues in the gastrointestinal tract. Signs of internal bleeding include painful or swollen extremities, a tender, rigid abdomen, and bruising. Painful or swollen extremities can indicate bleeding from an extremity injury, a tender, rigid abdomen can signal abdominal bleeding, and bruising can result from blood vessel damage. Therefore, the correct answer is 'C: vomiting bile,' as it is not a typical sign of internal bleeding.

5. People living in poverty are most likely to obtain health care from:

Correct answer: D

Rationale: People living in poverty often face barriers to accessing regular healthcare services, leading them to seek care in Emergency Departments or urgent care centers. These facilities are more accessible and do not require appointments or insurance, making them a common choice for individuals with limited resources. Neighborhood clinics, while a good option, may not always be available or affordable for those in poverty. Specialists provide specialized care but usually require a referral from a primary care provider, which individuals in poverty may not have consistent access to. Therefore, Emergency Departments or urgent care centers are the most likely sources of healthcare for people living in poverty.

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