Safe and Effective Care Environment Nclex PN Questions - Nurselytic

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.

Correct Answer: C

Rationale: The correct answer is 15:2. For one-person CPR on an adult, the ratio of compressions to ventilations is 15:2. This ratio ensures adequate oxygenation while maintaining effective circulation.
Choice A (5:1) and
Choice B (1:5) are incorrect ratios and do not align with the recommended guidelines for adult CPR.
Choice D (2:15) is also incorrect as it reverses the order of compressions and ventilations.

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.

Correct Answer: B

Rationale: The correct answer is B: Inability to communicate pain. In this scenario, the client's aphasia prevents them from verbally expressing their pain, which can lead to inadequate pain management if the healthcare team is not vigilant. The nurse must use alternative methods to assess and address the client's pain.

Choices A, C, and D, although important considerations in postoperative care, do not directly relate to the client's ability to communicate pain, which is crucial for effective pain management in this case.

Correct Answer: C

Rationale: The correct answer is 'The client verbalizes her body size accurately.' For clients with anorexia nervosa, body image disturbance is a common issue where they perceive themselves inaccurately. Verbalizing her body size accurately indicates progress towards correcting this distorted self-perception.

Choices A, B, and D are incorrect because they do not directly address the distorted body image perception seen in clients with anorexia nervosa.
Choice A focuses on knowledge of a maintenance diet, which is unrelated to body image perception.
Choice B involves assertiveness with family, which is more related to family dynamics.
Choice D addresses control of obsessive behaviors, which is not directly related to correcting the distorted body image perception.