NCLEX-PN
Safe and Effective Care Environment Nclex PN Questions Questions
Question 1 of 5
The nurse uses prioritization to determine all of the following except:
Correct Answer: C
Rationale: The correct answer is C: "treatment procedures." Prioritization in nursing involves determining the order of importance or urgency of tasks. Treatment procedures are standards of care that need to be followed as defined by the facility or nursing unit. They are not typically subject to prioritization but are mandatory based on established protocols. Time allotment for certain tasks, appropriate interventions, and the need for client education are all aspects that can be influenced by prioritization. For instance, prioritizing tasks helps in managing time effectively, selecting the most suitable interventions, and identifying the necessity for client education as part of the care plan.
Question 2 of 5
Which is the proper hand position for performing chest percussion?
Correct Answer: D
Rationale: The proper hand position for performing chest percussion is to cup the hands. Cupping the hands helps produce a vibration that aids in loosening respiratory secretions effectively. This technique is essential for therapeutic chest physiotherapy. Using the side of the hands, flattening the hands, or spreading the fingers of both hands do not generate the necessary vibration required for chest percussion. These hand positions are not considered proper techniques in this context and may not provide the desired therapeutic effect.
Question 3 of 5
In a disaster situation, the nurse assessing a diabetic client on insulin assesses for all of the following except:
Correct Answer: C
Rationale: In a disaster situation, when assessing a diabetic client on insulin, the nurse needs to consider various factors. Diabetic signs and symptoms, nutritional status, and availability of insulin are crucial aspects to assess for appropriate management during a crisis. However, bleeding problems are not directly related to diabetes or insulin therapy.
Therefore, assessing for bleeding problems is not a priority in this context.
Choice C, bleeding problems, is the correct answer as it is not typically associated with diabetes, unlike the other options provided.
Question 4 of 5
A client expresses anxiety about having magnetic resonance imaging performed. Which of the following is an appropriate response by the nurse?
Correct Answer: A
Rationale: The correct response acknowledges the client's anxiety and offers a practical solution to alleviate it, showing empathy and addressing the client's concerns. Offering a sedative to help relax during the test is a proactive approach to managing the client's anxiety.
Choices B and C dismiss the client's feelings by invalidating their anxiety, which can further escalate their distress.
Choice D downplays the client's feelings by implying they should not be worried, which does not effectively address the client's emotional state.
Question 5 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.