NCLEX-PN
Safe and Effective Care Environment Nclex PN Questions Questions
Extract:
Question 1 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 2 of 5
When caring for clients with Buck’s Traction, the major areas of importance should be:
Correct Answer: C
Rationale: When caring for clients with Buck’s Traction, the major areas of importance should be nutrition, elimination, comfort, and safety. Proper nutrition, including a diet high in protein with adequate fluids, is essential for healing and recovery. Elimination refers to maintaining regular bowel and bladder function. Comfort is crucial to ensure the patient's well-being while in traction, and safety measures should be followed to prevent complications.
Choices A, B, and D are incorrect. ROM exercises are not typically a primary concern with Buck’s Traction, making choices A and B incorrect. Isotonic exercises are not specifically related to the care of a client in Buck's Traction, making choice D incorrect.
Question 3 of 5
The LPN is preparing to clean a client's PEG tube.The following tasks should the nurse perform EXCEPT?
Correct Answer: B
Rationale: When cleaning a client's PEG tube, the nurse should perform tasks that focus on gentle cleaning and avoiding potential irritants.
Choice A is correct as gently removing crusty drainage helps maintain hygiene.
Choice C is important to prevent skin irritation and infection.
Choice D is appropriate for cleaning the area.
Choices B and D are incorrect.
Choice B is incorrect because pulling the tube in multiple directions can lead to dislodgement or injury.
Choice B is incorrect as talcum powder may irritate the stoma, and it is generally not recommended near PEG tubes.
Question 4 of 5
The LPN is checking for residual before administering enteral feeding through a PEG tube. Which of these steps is incorrect?
Correct Answer: C
Rationale: The incorrect step is choice C. The residual should be discarded before administering the tube feeding. Discarding the residual is essential to prevent contamination and ensure accurate measurement of the enteral feeding. Elevating the head of the bed by at least 30 degrees (choice
A) is correct as it helps prevent aspiration during feeding. Testing the pH level of the residual (choice
D) ensures proper placement of the tube. Withholding feeding if the residual is greater than 200mL (choice
B) is crucial to prevent overfeeding, making this statement correct.
Question 5 of 5
What is the correct instruction to give a client undergoing mammography?
Correct Answer: A
Rationale: The correct instruction for a client undergoing mammography is not to use underarm deodorant. Underarm deodorant can cause confusing shadows on the X-ray film, affecting the accuracy of the mammogram.
Choices B, C, and D are incorrect. While wearing comfortable clothing is advisable, it is not the primary instruction for mammography. Avoiding caffeine and bringing a list of current medications are not specific instructions related to mammography preparation and are therefore not the correct answers.