NCLEX-PN
Safe and Effective Care Environment Nclex PN Questions Questions
Extract:
Question 1 of 5
A client is on a clear liquid diet. She drinks half of a 12-ounce juice, 4 ounces of soup, and has a 6-ounce JELLO®. How many milliliters of fluid did the patient ingest?
Correct Answer: B
Rationale:
To calculate the total amount of fluid ingested, convert the ounces to milliliters. Given that 1 ounce is equal to 30 ml, the breakdown is as follows: Juice (6 ounces): 6 x 30 = 180 ml. Soup (4 ounces): 4 x 30 = 120 ml. JELLO® (6 ounces): 6 x 30 = 180 ml. Adding these together: 180 ml (juice) + 120 ml (soup) + 180 ml (JELLO®) = 480 ml.
Therefore, the patient ingested a total of 480 ml of fluid. It's important to note that gelatin, ice cream, and similar items that are liquid at room temperature should be considered as fluids.
Choice A, 440 ml, is incorrect as it does not account for the correct calculation.
Choice C, 220 ml, is incorrect as it is significantly lower than the correct total.
Choice D, 660 ml, is incorrect as it overestimates the total fluid intake.
Question 2 of 5
When the nurse is determining the appropriate size of an oropharyngeal airway to insert, what part of a client's body should she measure?
Correct Answer: B
Rationale: Correct! When sizing an oropharyngeal airway, the nurse should measure from the corner of the client's mouth to the tragus of the ear. This measurement ensures that the airway is the appropriate length to reach the pharynx without being too long or too short.
Choices B, C, and D are incorrect as they do not provide the correct anatomical landmarks for determining the size of an oropharyngeal airway. Measuring from the corner of the mouth to the tragus of the ear is a standard method to ensure proper airway size and prevent complications during airway management.
Question 3 of 5
Which sign might a healthcare professional observe in a client with a high ammonia level?
Correct Answer: A
Rationale: A high ammonia level can lead to hepatic encephalopathy, which includes symptoms like confusion, disorientation, and can progress to coma. Coma is a severe condition of unconsciousness. Edema is swelling caused by excess fluid trapped in body tissues, not typically associated with high ammonia levels. Hypoxia is a condition of inadequate oxygen supply to tissues and organs, not directly related to high ammonia levels. Polyuria is excessive urination, which is not a typical sign of high ammonia levels.
Question 4 of 5
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?
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.
Question 5 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.