Safe and Effective Care Environment Nclex PN Questions - Nurselytic

Correct Answer: A

Rationale: The correct answer is, "Since I'm not eating or drinking by mouth, I do not need to brush my teeth as often."? This statement indicates a need for teaching reinforcement because even when an NG tube is in place, the client should still brush their teeth twice daily. Good oral hygiene is essential to reduce the risk of introducing bacteria that may cause an infection.
Choice B is incorrect because remaining sitting up at a 45-degree angle or higher for 30 minutes after a feeding is a correct statement regarding NG tube care, promoting proper digestion and reducing the risk of aspiration.
Choice C is also incorrect because cleaning around the tube with water and mild soap is an appropriate practice to maintain cleanliness and prevent infection.
Choice D is incorrect because advising to avoid using Vaseline around the nostril and tube is a proper instruction to prevent skin breakdown, occlusion of the tube, and potential aspiration of Vaseline into the lungs.

Correct Answer: B

Rationale: The correct statement is, 'I need to wash my hair before the test.' Washing the hair is necessary to remove hair products that could interfere with electrode attachment to the scalp. Restricting food or drink is not required, except for avoiding caffeinated beverages. Removing metal jewelry is unnecessary for an electroencephalography procedure. Aspirin does not need to be avoided before the test; medications like anticonvulsants, tranquilizers, barbiturates, and sedatives are the ones that might need to be held.

Correct Answer: A

Rationale: The correct answer is 'Impaired Physical Mobility.' As Parkinson's disease progresses, clients may experience a shuffling gait and rigidity, leading to impaired physical mobility. This nursing diagnosis is relevant to address the functional limitations that may arise. 'Dysreflexia' is not typically associated with Parkinson's disease but rather with spinal cord injuries. 'Hypothermia' is a condition of abnormally low body temperature and is not a common complication of Parkinson's disease. 'Impaired Dentition' refers to dental issues and is not directly related to the progression of Parkinson's disease.

Correct Answer: C

Rationale: Pudding is a semi-solid and does not contribute significantly to fluid intake as it does not melt at room temperature.
Therefore, it should not be included in fluid intake calculations. On the other hand, ice chips, Jell-Oâ„¢, and IV fluid from an antibiotic piggyback are all sources of fluid that can significantly contribute to a client's total fluid intake and should be considered when calculating it. Ice chips and Jell-Oâ„¢ provide hydration upon melting, while IV fluid directly adds to the fluid volume in the body.

Correct Answer: D

Rationale: The correct answer is the capillary refill time of 3 seconds on the big toe. A capillary refill time longer than three seconds may indicate inadequate blood flow. Swollen feet, brown discoloration above the ankles, and leg pain are all signs of venous insufficiency to the lower extremities. These findings can suggest circulation issues and require further assessment and intervention.
Therefore, they should be of more concern compared to the capillary refill time of 3 seconds on the big toe, which is within the normal range of 2-3 seconds.