Safe and Effective Care Environment Nclex PN Questions - Nurselytic

Correct Answer: C

Rationale: The correct answer is 15:2. For one-person CPR on an adult, the ratio of compressions to ventilations is 15:2. This ratio ensures adequate oxygenation while maintaining effective circulation.
Choice A (5:1) and
Choice B (1:5) are incorrect ratios and do not align with the recommended guidelines for adult CPR.
Choice D (2:15) is also incorrect as it reverses the order of compressions and ventilations.

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.

Correct Answer: D

Rationale: In a case management clinical pathway for congestive heart failure, the focus is on providing medical care and support to the patient.

Choices A, B, and C are integral parts of managing congestive heart failure. Physician follow-up appointments with transportation ensure continuity of care, client education about medication use is crucial for adherence, and a nutritional consult helps in managing the patient's diet. However, insurance review for reimbursement is not typically part of the clinical pathway as it pertains to financial aspects and is usually handled by billing departments or external agencies.
Therefore, the correct answer is 'insurance review for reimbursement.'

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.

Correct Answer: B

Rationale: The correct answer is B: Inability to communicate pain. In this scenario, the client's aphasia prevents them from verbally expressing their pain, which can lead to inadequate pain management if the healthcare team is not vigilant. The nurse must use alternative methods to assess and address the client's pain.

Choices A, C, and D, although important considerations in postoperative care, do not directly relate to the client's ability to communicate pain, which is crucial for effective pain management in this case.