NCLEX-PN
Safe and Effective Care Environment Nclex PN Questions
1. What is the most effective way to prevent skin breakdown?
- A. assistive devices
- B. repositioning
- C. topical medications
- D. avoiding tape and bandages
Correct answer: V
Rationale: Repositioning is the most effective way to prevent skin breakdown. Repositioning helps relieve pressure on specific areas of the skin, reducing the risk of developing pressure ulcers. While assistive devices (Choice A) may be beneficial in some cases, they are not universally as effective as repositioning. Topical medications (Choice C) are primarily used for treating skin conditions and are not the primary focus for preventing skin breakdown. Avoiding tape and bandages (Choice D) is crucial to prevent skin irritation, but repositioning remains the most effective method to prevent skin breakdown.
2. To ensure proper immobilization and increase client comfort when using a rigid splint, what should be done?
- A. Place the client on a stretcher before splinting.
- B. Place the client on a long spine board before splinting.
- C. Pad the spaces between the body part and the splint.
- D. Ensure that the splint conforms to the body curves.
Correct answer: C
Rationale: Correct. When using a rigid splint, it is essential to pad the spaces between the body part and the splint to ensure proper immobilization and increase client comfort. This padding helps prevent pressure points and ensures a proper fit of the splint without causing discomfort. Placing the client on a stretcher or a long spine board before splinting (choices A and B) may be necessary for transportation but does not directly relate to the proper use of a rigid splint. Ensuring that the splint conforms to the body curves (choice D) is important but not as crucial as padding the spaces to prevent discomfort and ensure proper immobilization.
3. What should be included in the assessment of a client with a cast?
- A. capillary refill, warm toes, no discomfort.
- B. posterior tibial pulses, warm toes.
- C. moist skin essential, pain threshold.
- D. discomfort of the metacarpals.
Correct answer: A
Rationale: When assessing a client with a cast, it is crucial to check for capillary refill to ensure adequate circulation. Warm toes indicate good circulation, while the absence of discomfort suggests the cast is not causing any pain or undue pressure on the client. Therefore, choices B, C, and D are incorrect as they do not address the essential components of assessing a client with a cast.
4. What is a true statement about post-discharge follow-up?
- A. The nurse should ensure the client is educated on their discharge instructions.
- B. If the client seems stable, they likely do not need a follow-up visit.
- C. The physician is responsible for ensuring the client has their prescriptions upon discharge.
- D. If the client has questions, the nurse should address them before discharge.
Correct answer: A
Rationale: The correct statement is that the nurse should ensure the client is educated on their discharge instructions. This is crucial to promote continuity of care and prevent adverse events. The responsibility of educating the client falls on the nurse, not assuming stability without a follow-up visit. While the physician may prescribe medications, it is the nurse's responsibility to ensure the client has them before discharge. Instructing the client to bring up questions at a follow-up appointment is not ideal; all questions should be addressed before discharge to ensure the client's understanding and compliance.
5. Acyclovir (Zovirax) is the agent of choice for which of the following infections?
- A. HIV
- B. AIDS
- C. candida
- D. herpes
Correct answer: D
Rationale: Acyclovir is an antiviral medication specifically effective in treating herpes infections. It works by inhibiting the replication of the herpes virus, shortening the duration of the infection. While Acyclovir can be used in HIV and AIDS patients to treat opportunistic viral infections, it is not a primary drug for managing HIV or AIDS itself. Candida is a type of fungus, and infections caused by Candida are treated with antifungal medications, not antivirals like Acyclovir. Therefore, the correct answer is herpes.
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