NCLEX-PN
Safe and Effective Care Environment Nclex PN Questions
1. What is the appropriate ratio of cardiac compressions to ventilations in an adult client for one-person CPR?
- A. 5:1
- B. 1:5
- C. 15:2
- D. 2:15
Correct answer: 15:2
Rationale: The correct answer is 15:2. For one-person CPR on an adult, the ratio of compressions to ventilations is 15:2. This ratio ensures adequate oxygenation while maintaining effective circulation. Choice A (5:1) and Choice B (1:5) are incorrect ratios and do not align with the recommended guidelines for adult CPR. Choice D (2:15) is also incorrect as it reverses the order of compressions and ventilations.
2. Nonpharmacological pain management involves all of the following except:
- A. hypnosis alone.
- B. psychological care, including support groups.
- C. physical and psychological modalities.
- D. pain-reducing drugs only.
Correct answer: pain-reducing drugs only.
Rationale: Nonpharmacological pain management encompasses various strategies like hypnosis, psychological care, and physical and psychological modalities. The correct answer is 'pain-reducing drugs only' because nonpharmacological approaches do not solely rely on medications for pain management. Options A, B, and C are all valid components of nonpharmacological pain management. Hypnosis can help manage pain, psychological care including support groups can provide emotional support and coping strategies, and physical and psychological modalities encompass a wide range of interventions beyond just medication.
3. An LPN is working on the care plan for a client with diabetes mellitus. Which of these outcomes would be the most appropriate?
- A. The client will maintain a blood glucose level within the normal range of 70–110 (per facility policy) throughout my shift.
- B. The client will maintain a blood glucose level within normal range limits today.
- C. The client will maintain a blood glucose level within the normal range of 70–110 (per facility policy) throughout my shift.
- D. The client will maintain a blood glucose level within normal limits throughout my shift.
Correct answer: The client will maintain a blood glucose level within the normal range of 70–110 (per facility policy) throughout my shift.
Rationale: The correct answer is 'The client will maintain a blood glucose level within the normal range of 70–110 (per facility policy) throughout my shift.' This outcome is specific, measurable, and aligns with the goal of managing diabetes mellitus. Choice A is correct because it provides a clear target range (70-110) and includes adherence to facility policy, making it precise and goal-oriented. Choice B lacks specificity on the timeframe, and Choice D is vague in defining the target blood glucose range. In nursing care plans, outcomes should be well-defined, achievable, and measurable to effectively monitor the client's progress in managing their condition.
4. The nurse is preparing to administer the 9 am dose of IV antibiotics when she notes the IVAC cord is frayed with wiring visible. What action should be her priority for this client?
- A. Notify maintenance to come and check the pump immediately.
- B. Continue with the administration of the antibiotic and fill out an equipment maintenance request.
- C. Immediately discontinue the use of this IVAC pump and obtain a replacement.
- D. Tag the equipment for maintenance.
Correct answer: Immediately discontinue the use of this IVAC pump and obtain a replacement.
Rationale: The correct action is to immediately discontinue the use of the IVAC pump and obtain a replacement because the frayed cord poses a safety risk to the client. Continuing to use the pump with visible wiring could lead to electric shock or other serious harm to the client. Notifying maintenance to come and check the pump immediately (Choice A) may cause unnecessary delays in ensuring the client's safety. Continuing with the administration of the antibiotic and filling out an equipment maintenance request (Choice B) is unsafe as it ignores the immediate danger. Tagging the equipment for maintenance (Choice D) does not address the urgent need to protect the client from harm.
5. What does carrying a donor card for organ donation mean?
- A. medical care is altered to obtain organs for donation in the event of serious injuries
- B. the family or legally responsible party of a client has no decision-making authority in the event that the client is considered for organ donation
- C. a client is allowed to revoke their decision for organ donation at any time
- D. a client is considered an organ donor for multiple organs or tissues
Correct answer: a client is allowed to revoke their decision for organ donation at any time
Rationale: Carrying a donor card for organ donation signifies that an individual can decide to revoke their decision for organ donation at any point. This choice empowers the individual to change their mind regarding organ donation. The family or legally responsible party of a client still holds decision-making authority in the event that the client is considered for organ donation. When organ donation is being considered, all organs or tissues the donor wishes to donate are evaluated for donation suitability; it's not limited to just one organ or tissue. It's important to note that medical care for an individual is not altered to hasten the declaration of death for organ donation purposes; the focus is on providing immediate care and resuscitation to the individual.
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