NCLEX PN Test Bank

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A case manager is serving on a community task force on violence in schools. The members of the task force are planning to develop interventions to help prevent violence. According to the nursing process, which is the first activity that the case manager would suggest to the task force?

  • A. Teaching schoolchildren about the dangers of school violence
  • B. Conducting a community survey to assess community perceptions regarding school violence
  • C. Looking at what other communities are doing about school violence
  • D. Distributing flyers that identify the causes of school violence to families in the community
Correct Answer: B

Rationale: The correct answer is to conduct a community survey to assess community perceptions regarding school violence. In the nursing process, assessment is always the first step. By conducting a survey, the task force can gather important data about how the community perceives school violence, which is essential for developing effective interventions. Choices A, C, and D involve actions that come after the assessment phase. Teaching schoolchildren about the dangers of violence and distributing flyers are important activities but should come after understanding the community's perceptions and needs. Looking at what other communities are doing is valuable but should also follow a thorough assessment of the specific community's needs and perceptions.

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How is the information documented on incident reports used?

  • A. to analyze risk categories
  • B. to ensure compliance with regulations
  • C. to identify staff's educational needs
  • D. all of the above
Correct Answer: D

Rationale: The information documented on incident reports is used for various purposes, including analyzing risk categories, ensuring compliance with regulations, and identifying staff's educational needs. Incident reports provide valuable data that can be utilized in risk management, quality monitoring, and improvement programs. Therefore, the correct answer is 'all of the above.' Choices A, B, and C are all correct as incident reports are used for analyzing risk categories, ensuring compliance with regulations, and identifying staff's educational needs, respectively. Thus, the most comprehensive answer is 'all of the above.'

How far should the enema tube be inserted for a client to have a flatus-reducing enema?

  • A. 4 inches.
  • B. 6 inches.
  • C. 2 inches.
  • D. 8 inches.
Correct Answer: A

Rationale: The correct answer is to insert the enema tube 4 inches. Enema tubing must be passed beyond the internal sphincter, which is typically around 4 inches in an adult. Inserting the tube only 2 inches is not far enough to reach this point. On the other hand, inserting the tube 6 or 8 inches is too far and might cause trauma to the bowel, which is unnecessary for a flatus-reducing enema. Therefore, the correct insertion depth of the enema tube is crucial to ensure effectiveness and safety in providing the intended treatment.

A nurse is assisting with data collection of a client who has sustained circumferential burns of both legs. What should the nurse examine first?

  • A. Heart rate
  • B. Peripheral pulses
  • C. Blood pressure (BP)
  • D. Radial pulse rate
Correct Answer: B

Rationale: The priority assessment for a client with circumferential burns to the legs is to examine peripheral pulses. This is essential to ensure adequate circulation to the extremities. Circumferential burns can lead to compartment syndrome, causing decreased circulation to the affected limbs. Checking peripheral pulses is crucial to monitor for any signs of compromised circulation. While heart rate and blood pressure are important assessments in general, in the context of circumferential burns, the immediate concern is the risk of impaired circulation to the extremities. Therefore, assessing peripheral pulses takes precedence in this situation.

A nurse is planning task assignments for the day. Which assignment is the least appropriate for the nursing assistant?

  • A. Assisting a client with dysphagia in eating
  • B. Ambulating a client with Parkinson's disease
  • C. Providing hygiene to a client with dementia
  • D. Assisting a client with an above-the-knee amputation in showering
Correct Answer: A

Rationale: The least appropriate assignment for a nursing assistant would be assisting a client with dysphagia in eating. This task requires specialized skills and knowledge to prevent complications such as choking and aspiration. Ambulating a client with Parkinson's disease, providing hygiene to a client with dementia, and assisting a client with an above-the-knee amputation in showering are tasks that a nursing assistant can safely perform without significant risk of complications. Assisting a client with dysphagia in eating involves higher risks and requires specific training, making it the least appropriate choice for a nursing assistant.

Which of the following ethnic groups is at highest risk in the United States for pesticide-related injuries?

  • A. Native American
  • B. Asian-Pacific
  • C. Norwegian
  • D. Hispanic
Correct Answer: D

Rationale: The correct answer is 'Hispanic.' Hispanic individuals in the United States are at a higher risk for pesticide-related injuries due to their representation among migrant workers in agricultural settings. This exposure to pesticides in their work environments increases their risk compared to other ethnic groups. Choice A, 'Native American,' although indigenous populations may face environmental health disparities, the higher risk in this context is among Hispanic individuals. Choice B, 'Asian-Pacific,' and Choice C, 'Norwegian,' do not have the same level of exposure to pesticides as Hispanic migrant workers, making them less susceptible to pesticide-related injuries.

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