NCLEX-PN
Safe and Effective Care Environment Nclex PN Questions Questions
Extract:
Question 1 of 5
A client with cirrhosis of the liver presents with ascites. The physician is to perform a paracentesis. For safety, the nurse should ask the client to:
Correct Answer: C
Rationale: When performing a paracentesis, the client must be sitting up to allow the fluid to settle in the lower abdomen.
To prevent trauma to the bladder while inserting a needle to aspirate the fluid, the bladder must be empty.
Choice A is incorrect as excessive fluid intake can make the procedure more difficult due to increased abdominal distension.
Choice B is unrelated to the procedure of paracentesis.
Choice D is incorrect as the client should be sitting up, not in the prone position, during the procedure.
Question 2 of 5
The LPN is auscultating for bowel sounds and hears between 3 and 4 bowel sounds per minute. This is a somewhat expected finding for which of these clients?
Correct Answer: D
Rationale: When recovering from general anesthesia, hypoactive bowel sounds can be expected due to the effects of the anesthesia on gut motility. For the other clients, hearing less than 5 bowel sounds per minute would indicate an abnormal finding. In the context of the given situation, the client recovering from knee replacement surgery aligns with the expected range of bowel sounds post-general anesthesia.
Therefore, choice D is the correct answer.
Choices A, B, and C present scenarios where hearing less than 5 bowel sounds per minute would be abnormal, indicating potential issues that need further evaluation.
Question 3 of 5
The LPN is caring for a client with an NG tube, and the RN administers evening medications through the NG tube. The client asks if he can lie down when the nurse leaves the room. What is the most appropriate response?
Correct Answer: A
Rationale: After administering medication through an NG tube, the client should remain upright for 30 minutes to ensure proper absorption of the medications.
Therefore, the most appropriate response is to advise the client to lie down in 1 hour.
Choice B is incorrect because waiting only 30 minutes may not provide sufficient time for the medications to be fully absorbed, as the recommended time is 30 minutes.
Choice C is misleading as it incorrectly suggests that lying down in about 30 minutes is acceptable, which could compromise medication effectiveness.
Choice D is incorrect as it does not provide accurate information regarding the appropriate timing for lying down after NG tube medication administration, potentially leading to decreased medication absorption.
Question 4 of 5
After administering medication through an NG tube, the client asks if he can lie down when the nurse leaves the room. What is the most appropriate response?
Correct Answer: C
Rationale: The correct answer is to inform the client that they can lie down in about 30 minutes. After administering medication through an NG tube, it is recommended that the client remains upright for about 30 minutes to ensure proper absorption of the medications. Option A is incorrect as waiting for 1 hour is unnecessary. Option B is incorrect as the specified timeframe and condition given are not standard practice for lying down after NG tube medication administration. Option D is incorrect as it lacks guidance on the appropriate waiting time and does not emphasize the importance of waiting before lying down for optimal medication absorption.
Question 5 of 5
When placing a Foley catheter in a female client, what is the correct order of steps?
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.