Safe and Effective Care Environment Nclex PN Questions - Nurselytic

Correct Answer: V

Rationale: Repositioning is the most effective way to prevent skin breakdown. Repositioning helps relieve pressure on specific areas of the skin, reducing the risk of developing pressure ulcers. While assistive devices (
Choice
A) may be beneficial in some cases, they are not universally as effective as repositioning.
Topical medications (
Choice
C) are primarily used for treating skin conditions and are not the primary focus for preventing skin breakdown. Avoiding tape and bandages (
Choice
D) is crucial to prevent skin irritation, but repositioning remains the most effective method to prevent skin breakdown.

Correct Answer: A

Rationale: The correct action for the nurse to take when sensing a tingling sensation while lowering the bed with a comatose client is to unplug the bed's power source. This should be the initial step as there may be a fault in the bed's grounding. Removing the client from the bed immediately is not safe until the electrical issue is resolved. Notifying the biomedical department is important but should come after ensuring the immediate safety of the client. Turning off the oxygen is not necessary unless there is a specific issue related to oxygen delivery, which is not indicated in this scenario.

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: B

Rationale: When making an occupied bed, using a bath blanket or top sheet is important as it keeps the client warm and provides privacy, ensuring their comfort and dignity. Keeping the bed in the low position is crucial for the safety of the client, preventing falls and injuries. Constantly keeping side rails raised on both sides is unnecessary and may restrict the client's movement unnecessarily. Moving back and forth from one side to the other when adjusting the linens is inefficient and disrupts the workflow; it is more effective to work systematically from one side to the other to ensure proper bed-making.

Correct Answer: B

Rationale: A client room environment should include a made bed to provide a sense of neatness and comfort, ensuring the client's safety at all times. It is important to maintain a clutter-free area to prevent accidents and promote a relaxing environment. Having hygiene articles nearby allows the client easy access to personal care items.
Choice A is incorrect because while fresh water and thermostat regulation are important, they are not essential components of a client room environment.
Choice C is incorrect as it emphasizes more on cleaning procedures rather than creating a comfortable and safe environment for the client.
Choice D is incorrect as it emphasizes odor control and storage rather than the client's comfort and safety.