Safe and Effective Care Environment Nclex PN Questions

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In a disaster triage situation, which of the following should the nurse be least concerned with regarding a client in crisis?

  • A. ability to breathe
  • B. pallor or cyanosis of the skin
  • C. number of accompanying family members
  • D. motor function
Correct Answer: C

Rationale: During a disaster triage situation where quick decisions are crucial, the nurse's primary focus should be on factors directly related to the patient's immediate condition and survival. The ability to breathe, pallor or cyanosis of the skin, and motor function are critical indicators of a patient's health status and need for urgent intervention. In contrast, the number of accompanying family members, although important for emotional support, is not a priority when assessing and prioritizing care during a crisis. While emotional support is valuable, the focus in triage is on identifying and addressing the most critical and life-threatening issues first to maximize survival chances. Therefore, the nurse should be least concerned with the number of accompanying family members as it does not directly impact the patient's immediate medical needs in a crisis situation. Choices A, B, and D are all crucial factors to assess a client's health status and determine the urgency of intervention during a disaster triage. The ability to breathe indicates respiratory function, pallor or cyanosis of the skin reflect circulatory and oxygenation status, and motor function can hint at neurological impairment or injury, all of which are vital in determining the severity of the crisis and the immediate medical needs of the patient.

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Which type of diet should the nurse provide to help a client who has major burns maintain a positive nitrogen balance?

  • A. high protein
  • B. high carbohydrate
  • C. low carbohydrate
  • D. low protein
Correct Answer: A

Rationale: Clients with major burns are in a hypermetabolic state, leading to increased protein catabolism. Therefore, a high-protein diet is essential to help them maintain a positive nitrogen balance and support wound healing. High carbohydrate diets do not directly contribute to achieving a positive nitrogen balance, making choice B incorrect. Similarly, low carbohydrate diets are not recommended for clients with major burns as carbohydrates provide essential energy needed for healing. Low protein diets are contraindicated for clients with major burns as they require higher protein intake to support tissue repair and prevent further breakdown.

All of the following clients are in need of an emergency assessment except:

  • A. a bleeding client who has an injury from falling debris.
  • B. an unresponsive client.
  • C. a client with an old injury.
  • D. a pregnant woman with imminent delivery.
Correct Answer: C

Rationale: The correct answer is 'a client with an old injury.' Emergency assessments are required for immediate and life-threatening situations. Clients A, B, and D are in need of emergency assessments due to their critical conditions. Choice C, a client with an old injury, does not require an emergency assessment as it is not an acute or life-threatening situation. While the client with an old injury may still need medical attention, it does not necessitate an emergency assessment as the condition is not currently life-threatening or in need of immediate intervention.

An 80-year-old aphasic CVA client had abdominal surgery 2 days ago. Which of the following puts this client at the highest risk for inadequate pain management?

  • A. Inability to turn, cough, and breathe deeply
  • B. Inability to communicate pain
  • C. Inability to ambulate freely
  • D. Inability to use a bedside commode
Correct Answer: B

Rationale: The correct answer is B: Inability to communicate pain. In this scenario, the client's aphasia prevents them from verbally expressing their pain, which can lead to inadequate pain management if the healthcare team is not vigilant. The nurse must use alternative methods to assess and address the client's pain. Choices A, C, and D, although important considerations in postoperative care, do not directly relate to the client's ability to communicate pain, which is crucial for effective pain management in this case.

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.

While observing a client using crutches for a leg injury, which action would indicate a need for more education by the LPN?

  • A. The client places the top padding 1-2 inches below the axilla with a firm grip on the handles.
  • B. The client rests the axilla on the top padding and loosely grips the handles with hands.
  • C. The client has a slight bend in the elbow when using the handles.
  • D. When going down the stairs, the client leads with the injured leg.
Correct Answer: B

Rationale: The correct answer is B. Resting the axilla on the top padding can cause nerve damage; instead, the client should place the top padding 1-2 inches below the axilla with a firm grip on the handles for proper support and stability while using crutches. Having a slight bend in the elbow when using the handles (choice C) is a correct technique to ensure proper weight distribution. Leading with the uninjured leg when going down the stairs (choice D) is the correct way to maintain balance and prevent further injury to the injured leg. Therefore, choice B indicates a need for more education to prevent potential nerve damage and ensure safe crutch use.

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