NCLEX-PN
Safe and Effective Care Environment Nclex PN Questions Questions
Extract:
Question 1 of 5
To remove hard contact lenses from an unresponsive client, what should the nurse do?
Correct Answer: D
Rationale: When removing hard contact lenses from an unresponsive client, the nurse should ensure that the lens is centered on the cornea before gently manipulating the lids to release the lens. This approach helps prevent scratching the cornea. Gently maneuvering the upper and lower eyelids assists in loosening the lens for easy removal. Options A, B, and C are incorrect because irrigating the eye, grasping the lens, or wearing sterile gloves are not recommended methods for removing hard contact lenses. It is crucial to handle the situation delicately to avoid causing harm or discomfort to the client.
Question 2 of 5
All of the following interventions should be performed when fetal heart monitoring indicates fetal distress except:
Correct Answer: C
Rationale: When fetal distress is indicated, interventions are aimed at improving oxygenation and blood flow to the fetus. Increasing maternal fluids helps improve blood flow and oxygen delivery, administering oxygen increases oxygenation levels, and turning the mother can help optimize fetal oxygenation. Decreasing maternal fluids would negatively impact blood volume and can worsen fetal distress, making it the exception among the listed interventions.
Therefore, decreasing maternal fluids should not be performed when fetal distress is present.
Question 3 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 4 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 5 of 5
To remove hard contact lenses from an unresponsive client, what should the nurse do?
Correct Answer: D
Rationale: When removing hard contact lenses from an unresponsive client, the nurse should ensure that the lens is centered on the cornea before gently manipulating the lids to release the lens. This approach helps prevent scratching the cornea. Gently maneuvering the upper and lower eyelids assists in loosening the lens for easy removal. Options A, B, and C are incorrect because irrigating the eye, grasping the lens, or wearing sterile gloves are not recommended methods for removing hard contact lenses. It is crucial to handle the situation delicately to avoid causing harm or discomfort to the client.