Safe and Effective Care Environment Nclex PN Questions - Nurselytic

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: '4'. The FLACC pain scale assesses pain in non-verbal patients based on five categories: Face, Legs, Activity, Cry, and Consolability. In this case, the client exhibits occasional grimacing (1 point), relaxed legs (0 points), squirming (1 point), moans and whimpers (1 point), and is distractible (1 point). Adding these points together results in a total pain score of 4.
Therefore, the LPN should document a pain score of 4 for this non-verbal client.

Choices A, C, and D are incorrect as they do not accurately reflect the total pain score based on the given findings.

Correct Answer: D

Rationale: The correct answer is intact recent and remote memory. Intact memory function indicates that the client is less likely to be at risk for falls as it suggests cognitive awareness and orientation, which are important for safety.

Choices A, B, and C are risk factors for falls: a history of dizziness can lead to imbalance, the need for a wheelchair due to reduced mobility can increase fall risk, and weakness and fatigue when climbing stairs indicate physical limitations that predispose a client to falls.
Therefore, these options would suggest an increased risk for falls.

Correct Answer: B

Rationale: When assessing a client’s motor skills, it is crucial to evaluate their strength, balance, and coordination as these directly impact their motor abilities. Strength is essential to perform tasks, balance is required for stability, and coordination is necessary for smooth movements. However, knowledge of ergonomics, while beneficial for overall understanding, is not directly related to assessing motor skills. The focus should be on physical abilities rather than theoretical knowledge of ergonomics.
Therefore, testing the client’s knowledge of ergonomics is the least important when evaluating their motor skills.

Correct Answer: C

Rationale: The correct answer is, 'I can try to incorporate any sleep rituals or an ideal bedtime into your routine.'
To promote rest and sleep, the provider should consider incorporating the client's preferred sleep rituals or bedtime routine. This statement shows an understanding of the importance of individualizing care to promote restful sleep.

Choices A, B, and D do not directly address promoting rest and sleep.
Choice A focuses on postponing assessments,
Choice B addresses napping during the day, and
Choice D mentions multiple interruptions at night, none of which directly support promoting rest and sleep for the client.