NCLEX-PN
Safe and Effective Care Environment Nclex PN Questions Questions
Extract:
Question 1 of 5
When the nurse is determining the appropriate size of an oropharyngeal airway to insert, what part of a client's body should she measure?
Correct Answer: B
Rationale: Correct! When sizing an oropharyngeal airway, the nurse 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 reach the pharynx without being too long or too short.
Choices B, C, and D are incorrect as they do not provide the correct anatomical landmarks for determining the size of an oropharyngeal airway. Measuring from the corner of the mouth to the tragus of the ear is a standard method to ensure proper airway size and prevent complications during airway management.
Question 2 of 5
A client with dysphagia is ready to eat lunch. Which of these foods on the tray would be best to start with when assisting the client?
Correct Answer: B
Rationale: The correct choice is apple juice with a liquid thickener. A client with dysphagia is at risk for aspiration, so it is crucial to start with liquids and assess the client's ability to swallow before introducing solid foods. Using a liquid thickener with apple juice allows the healthcare provider to evaluate swallowing function. Jell-Oâ„¢, although it melts into a clear liquid, should be avoided initially as it may not provide a clear assessment of swallowing ability. Diced fruit and toast are solid foods that should be introduced only after the client's swallowing ability with liquids has been assessed.
Question 3 of 5
When removing a client's gown with an intravenous line, what should the nurse do?
Correct Answer: C
Rationale: The correct action when removing a client's gown with an intravenous line is to thread the bag and tubing through the gown sleeve while keeping the line intact. This method ensures that the system remains sterile and reduces the risk of infection. Temporarily disconnecting the tubing at a point close to the client or from the container introduces the potential for contamination. Cutting the gown with scissors should only be done in emergencies as it is not a standard practice and can compromise the integrity of the intravenous line.
Therefore, the most appropriate and safe method is to thread the bag and tubing through the gown sleeve.
Question 4 of 5
Which of these should not be included when calculating a client's fluid intake?
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.
Question 5 of 5
Which of the following foods might a client with hypercholesterolemia need to decrease intake of?
Correct Answer: B
Rationale: A client with hypercholesterolemia should decrease their intake of foods high in cholesterol. Hamburgers, being red meat, have a high cholesterol content, hence should be decreased in the diet. Broiled catfish, wheat bread, and fresh apples are not high in cholesterol, so there is no need to decrease their intake. Broiled catfish is a lean source of protein, wheat bread is a complex carbohydrate, and fresh apples are a good source of fiber and vitamins.
Therefore, hamburgers are the correct choice to decrease intake for a client with hypercholesterolemia.