what is the most effective way to prevent skin breakdown
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Nursing Elites

NCLEX-PN

Safe and Effective Care Environment Nclex PN Questions

1. What is the most effective way to prevent skin breakdown?

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. Which of the following conditions has a severe complication of respiratory failure?

Correct answer: B

Rationale: Guillain-Barr� syndrome is characterized by a severe complication of respiratory failure due to the involvement of the peripheral nerves that control breathing. While Bell's palsy, trigeminal neuralgia, and tetanus are also conditions affecting peripheral nerves, they do not typically lead to respiratory failure like Guillain-Barr� syndrome. Bell's palsy causes facial muscle weakness, trigeminal neuralgia results in severe facial pain, and tetanus leads to muscle stiffness and spasms, but none of these conditions directly involve respiratory failure.

3. While on the wound care team, the nurse notices that a fellow nurse opens extra colloid dressings that are often thrown away when they are not needed. What should the nurse do?

Correct answer: B

Rationale: The correct answer is to discuss with the colleague the concern about wasting supplies. By addressing this issue, the nurse can promote cost-effective care within the unit. While it may not directly impact client care, the wastage of supplies affects the unit's supply cost, making choice A incorrect. Choice C is incorrect as it assumes the charge nurse is solely responsible for the ordering process and overlooks the opportunity for direct communication between colleagues. Choice D is incorrect as it involves taking matters into one's own hands rather than addressing the issue through communication and collaboration.

4. When working with elderly clients, the healthcare provider should keep in mind that falls are most likely to happen to the elderly who are:

Correct answer: C

Rationale: The correct answer is 'hospitalized.' Elderly individuals are at a higher risk of falls, especially when they are in new environments like hospitals due to unfamiliarity with the surroundings, medications, and potential mobility challenges. Being in a hospital can disrupt their usual routines and increase the risk of falls. Choice A ('in their 80s') is not as directly related to the increased risk of falls in a hospital environment. Choice B ('living at home') is a common setting for the elderly but does not address the specific risk associated with being hospitalized. Choice D ('living on only Social Security income') is unrelated to the risk of falls based on the environment.

5. After assigning tasks, what is the nurse's primary responsibility?

Correct answer: D

Rationale: The nurse's primary responsibility after assigning tasks is to follow up with each staff member regarding the task's performance and outcomes. This ensures accountability and quality care delivery. Allowing staff members to make judgments independently can compromise patient safety if they lack the necessary knowledge or experience. While documenting task completion is important, it should follow the follow-up to assess outcomes. Assigning incomplete tasks to the next shift is not ideal as it may result in unmet patient needs and increased workload for the next shift.

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