NCLEX-PN
Safe and Effective Care Environment Nclex PN Questions Questions
Extract:
Question 1 of 5
When the healthcare provider is determining the appropriate size of an oropharyngeal airway to insert, what part of a client's body should they measure?
Correct Answer: A
Rationale: When selecting the correct size of an oropharyngeal airway, the healthcare provider should measure from the corner of the client's mouth to the tragus of the ear. This measurement ensures that the airway is the appropriate length to maintain a clear air passage for exchange. Measuring from the corner of the eye to the top of the ear (
Choice
B) is inaccurate and not a standard measurement for selecting the size of an oropharyngeal airway. Measuring from the tip of the chin to the sternum (
Choice
C) is irrelevant to determining the correct size of the airway. Similarly, measuring from the tip of the nose to the earlobe (
Choice
D) is also incorrect and does not provide the necessary measurement for selecting an oropharyngeal airway size.
Question 2 of 5
When making an occupied bed, what is important for the nurse to do?
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.
Question 3 of 5
Which fetal heart monitor pattern can indicate cord compression?
Correct Answer: A
Rationale: Variable decelerations can indicate cord compression as they are caused by umbilical cord compression or prolapse. This pattern shows an abrupt decrease in heart rate with an erratic shape, often resembling a V or W. Early decelerations (choice
B) are typically caused by head compression during contractions and are considered benign. Bradycardia (choice
C) is a consistent low heart rate below 110 bpm and is not specific to cord compression. Tachycardia (choice
D) is an abnormally high heart rate above 160 bpm and is not associated with cord compression.
Question 4 of 5
While observing a client using crutches for a leg injury, which action would indicate a need for more education by the LPN?
Correct Answer: B
Rationale: The correct answer is B. Resting the axilla on the top padding can cause nerve damage; instead, the client should place the top padding 1-2 inches below the axilla with a firm grip on the handles for proper support and stability while using crutches. Having a slight bend in the elbow when using the handles (choice
C) is a correct technique to ensure proper weight distribution. Leading with the uninjured leg when going down the stairs (choice
D) is the correct way to maintain balance and prevent further injury to the injured leg.
Therefore, choice B indicates a need for more education to prevent potential nerve damage and ensure safe crutch use.
Question 5 of 5
What does carrying a donor card for organ donation mean?
Correct Answer: C
Rationale: Carrying a donor card for organ donation signifies that an individual can decide to revoke their decision for organ donation at any point. This choice empowers the individual to change their mind regarding organ donation. The family or legally responsible party of a client still holds decision-making authority in the event that the client is considered for organ donation. When organ donation is being considered, all organs or tissues the donor wishes to donate are evaluated for donation suitability; it's not limited to just one organ or tissue. It's important to note that medical care for an individual is not altered to hasten the declaration of death for organ donation purposes; the focus is on providing immediate care and resuscitation to the individual.