NCLEX-PN
Safe and Effective Care Environment Nclex PN Questions Questions
Question 1 of 5
The LPN is caring for a 32-year-old female client who is 8 hours post-op after a tonsillectomy. Which of these actions would be appropriate for the nurse to take?
Correct Answer: A
Rationale: The appropriate action for the nurse to take is to inform the client that ear pain may occur and is normal after a tonsillectomy. Referred pain in the ear is common due to related nerve pathways. It is essential to educate the client about this to alleviate concerns. Providing ice water and a straw is not recommended as they may irritate the throat and disturb the healing process. Hot beverages like tea should also be avoided for the same reason. While monitoring vitals every 15 minutes is crucial in the immediate postoperative period for early identification of any complications, it is not the most appropriate action in this scenario where addressing the client's concerns and providing education is key.
Question 2 of 5
Which type of diet should the nurse provide to help a client who has major burns maintain a positive nitrogen balance?
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.
Question 3 of 5
Which of these would be an appropriate meal for a client with Celiac disease?
Correct Answer: C
Rationale: For individuals with Celiac disease, it's crucial to avoid gluten-containing foods.
Choice C, which includes chicken, rice, apple, and tapioca pudding, is the most suitable option as all these foods are naturally gluten-free. Rice, fruits, vegetables, meat, dairy, and tapioca are all safe gluten-free options. Oats can be gluten-free if specially labeled, but many are processed on shared equipment with wheat. Granola often contains oats that may have been exposed to gluten. Dried and prepackaged fruits may contain gluten additives. Rye is a wheat derivative, and cream sauces usually contain flour as a base, making choices A and B inappropriate for individuals with Celiac disease.
Question 4 of 5
A child comes to the clinic with a skin rash. The maculopapular lesions are distributed around the mouth and have honey-colored drainage. The caregiver states that the rash is getting worse and seems to spread with the child's scratching. Which of the following advisory comments should be given?
Correct Answer: C
Rationale: The scenario describes classic impetigo, which typically presents with maculopapular lesions around the mouth with honey-colored drainage, worsening with scratching. It is important to advise the caregiver that the history and presentation are indicative of impetigo, an infectious skin condition caused by bacteria. Treatment usually involves antibiotic therapy.
Choice A is incorrect because chickenpox typically presents with a vesicular rash following a history of high fever.
Choice B is incorrect as impetigo is contagious and requires precautions to prevent the spread of infection.
Choice D is incorrect as impetigo is contagious irrespective of open wounds or lesions in others.
Question 5 of 5
When caring for clients with Buck’s Traction, the major areas of importance should be:
Correct Answer: C
Rationale: When caring for clients with Buck’s Traction, the major areas of importance should be nutrition, elimination, comfort, and safety. Proper nutrition, including a diet high in protein with adequate fluids, is essential for healing and recovery. Elimination refers to maintaining regular bowel and bladder function. Comfort is crucial to ensure the patient's well-being while in traction, and safety measures should be followed to prevent complications.
Choices A, B, and D are incorrect. ROM exercises are not typically a primary concern with Buck’s Traction, making choices A and B incorrect. Isotonic exercises are not specifically related to the care of a client in Buck's Traction, making choice D incorrect.