NCLEX-PN
Safe and Effective Care Environment Nclex PN Questions Questions
Extract:
Question 1 of 5
Which of the following devices may be applicable to a bedridden patient to address potential venous insufficiency?
Correct Answer: B
Rationale: For a bedridden patient with potential venous insufficiency, sequential compression devices (SCDs) and compression stockings are appropriate choices. SCDs help improve venous return from the lower extremities by applying sequential pressure, aiding circulation. Compression stockings also assist in preventing blood from pooling in the legs by applying pressure to support venous return. Shear-reducing mattresses are not directly related to managing venous insufficiency, as they are designed to reduce friction and shear forces on the skin to prevent pressure ulcers. Non-skid socks are primarily used for fall prevention and have no direct impact on venous insufficiency.
Question 2 of 5
The client has a new prosthetic hip, and the nurse is repositioning them. Which position should be avoided to prevent injury to the new prosthetic hip?
Correct Answer: B
Rationale: The correct answer is 'adduction of the hip.' When a client has a new prosthetic hip, adduction (movement of the leg toward the midline of the body) should be avoided to prevent injury to the new prosthetic hip. Abduction (movement of the leg away from the midline) is typically allowed and may even be encouraged. Flexing the hip at certain degrees is acceptable, but adduction should be avoided to prevent complications or dislocation of the prosthetic hip.
Therefore, options A, C, and D are incorrect because they do not pose a direct risk to the new prosthetic hip compared to adduction.
Question 3 of 5
To remove hard contact lenses from an unresponsive client, what should the nurse do?
Correct Answer: D
Rationale: When removing hard contact lenses from an unresponsive client, the nurse should ensure that the lens is centered on the cornea before gently manipulating the lids to release the lens. This approach helps prevent scratching the cornea. Gently maneuvering the upper and lower eyelids assists in loosening the lens for easy removal. Options A, B, and C are incorrect because irrigating the eye, grasping the lens, or wearing sterile gloves are not recommended methods for removing hard contact lenses. It is crucial to handle the situation delicately to avoid causing harm or discomfort to the client.
Question 4 of 5
Which type of diet should the nurse provide to help a client who has major burns maintain a positive nitrogen balance?
Correct Answer: A
Rationale: Clients with major burns are in a hypermetabolic state, leading to increased protein catabolism.
Therefore, a high-protein diet is essential to help them maintain a positive nitrogen balance and support wound healing. High carbohydrate diets do not directly contribute to achieving a positive nitrogen balance, making choice B incorrect. Similarly, low carbohydrate diets are not recommended for clients with major burns as carbohydrates provide essential energy needed for healing. Low protein diets are contraindicated for clients with major burns as they require higher protein intake to support tissue repair and prevent further breakdown.
Question 5 of 5
What is the most effective way to prevent skin breakdown?
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.