Nclex PN Questions and Answers - Nurselytic

Correct Answer: B

Rationale: When a client sustains a fall, the nurse must first assess the client. The nurse should check the client's level of consciousness and vital signs to determine the severity of the situation and provide appropriate care promptly. This immediate assessment is crucial in ensuring the client's immediate needs are addressed. Asking the nursing assistant to complete an incident report (choice
A) is not the priority as the client's condition needs immediate attention. Contacting the unit secretary to call the client's health care provider (choice
C) can be done after the initial assessment has been completed. Asking the nursing assistant to assist in getting the client back to bed (choice
D) should only be considered after ensuring the client is stable and safe to move.

Correct Answer: B

Rationale: In this scenario, the most appropriate way for the LPN to proceed is to report the conflict to the assigned charge nurse of the unit. Following the chain of command is crucial in a professional setting to address conflicts effectively. Reporting the issue to the charge nurse, who is the immediate supervisor, allows for a structured approach to resolving the conflict. Reporting directly to higher levels such as the director of nursing or nurse manager may bypass the appropriate hierarchy and could create unnecessary tension. Attempting to resolve the issue independently with the other nurse may not be effective if previous attempts have failed, making it essential to involve the immediate supervisor.

Correct Answer: B

Rationale: When a client sustains a fall, the nurse must first assess the client. The nurse should check the client's level of consciousness and vital signs to determine the severity of the situation and provide appropriate care promptly. This immediate assessment is crucial in ensuring the client's immediate needs are addressed. Asking the nursing assistant to complete an incident report (choice
A) is not the priority as the client's condition needs immediate attention. Contacting the unit secretary to call the client's health care provider (choice
C) can be done after the initial assessment has been completed. Asking the nursing assistant to assist in getting the client back to bed (choice
D) should only be considered after ensuring the client is stable and safe to move.

Correct Answer: A

Rationale: The correct answer is that clinical pathways do not necessarily require daily updates. Clinical pathways can be customized to be updated daily, weekly, or at other intervals based on patient needs and facility protocols.
Choice A is inaccurate as daily updates are not always mandatory for clinical pathways.

Choices B, C, and D are accurate features of clinical pathways: they depict the expected client response to the diagnosis, aim for improvement or discharge, and are grounded in evidence-based practices to ensure optimal care.

Correct Answer: C

Rationale: In most situations, a wedding band may be taped in place and worn during a surgical procedure. However, if there is a possibility that the client will experience swelling of the hand or fingers, the wedding band should be removed. On admission to a healthcare facility, the client is usually asked to sign a form that releases the agency from responsibility if a client's valuables are lost. After a mastectomy with axillary lymph node dissection, the client is at risk for lymphedema, which can result in swelling of the arm and hand on the affected side.
Therefore, the appropriate nursing action is to ask the client to remove the wedding band and explain why. This ensures the client's safety and prevents potential complications. Option A is incorrect because taping the wedding band may not be sufficient if swelling occurs. Option B is incorrect as it does not address the immediate need to remove the wedding band. Option D is incorrect because it fails to provide the client with the necessary information about the potential risks of wearing the wedding band during surgery.