NCLEX-PN
Safe and Effective Care Environment Nclex PN Questions Questions
Extract:
Question 1 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 2 of 5
When the healthcare provider is determining the appropriate size of an oropharyngeal airway to insert, what part of a client's body should they measure?
Correct Answer: A
Rationale: When selecting the correct size of an oropharyngeal airway, the healthcare provider 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 maintain a clear air passage for exchange. Measuring from the corner of the eye to the top of the ear (
Choice
B) is inaccurate and not a standard measurement for selecting the size of an oropharyngeal airway. Measuring from the tip of the chin to the sternum (
Choice
C) is irrelevant to determining the correct size of the airway. Similarly, measuring from the tip of the nose to the earlobe (
Choice
D) is also incorrect and does not provide the necessary measurement for selecting an oropharyngeal airway size.
Question 3 of 5
The nurse is teaching a client about erythema infectiosum. Which of the following factors is not correct?
Correct Answer: B
Rationale: The correct answer is that the disorder is uncommon in adults. Erythema infectiosum, also known as Fifth's disease, commonly affects children and is characterized by a 'slapped face' appearance. It is associated with a rash and sometimes a low-grade fever.
Therefore, the statement 'The disorder is uncommon in adults' is not correct, making it the correct answer. The other statements about the presence of a rash, 'slapped face' appearance, and the possibility of a fever are accurate in the context of erythema infectiosum.
Question 4 of 5
When removing a client's gown with an intravenous line, what should the nurse do?
Correct Answer: C
Rationale: The correct action when removing a client's gown with an intravenous line is to thread the bag and tubing through the gown sleeve while keeping the line intact. This method ensures that the system remains sterile and reduces the risk of infection. Temporarily disconnecting the tubing at a point close to the client or from the container introduces the potential for contamination. Cutting the gown with scissors should only be done in emergencies as it is not a standard practice and can compromise the integrity of the intravenous line.
Therefore, the most appropriate and safe method is to thread the bag and tubing through the gown sleeve.
Question 5 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.