Nclex PN Questions and Answers

Nclex PN Questions and Answers Related

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A nurse witnesses a client sign the consent form for surgery with the surgeon. As the surgeon leaves, the client starts to speak and then stops. The nurse asks if the client has further questions, and he says, "I don't want to bother the surgeon."? The nurse should ____.

  • A. acknowledge the client's wish not to bother the surgeon and tell the client to let you know if they change their mind
  • B. acknowledge the client's wish not to bother the surgeon and answer all of their questions, as appropriate
  • C. go get the surgeon to answer all of the client's questions
  • D. answer any questions as appropriate as well as have the surgeon come back to answer any questions if needed
Correct Answer: D

Rationale: In this scenario, the nurse should prioritize the client's understanding and comfort. While acknowledging the client's wish not to bother the surgeon is important, it is equally crucial to ensure that the client's questions are answered appropriately and thoroughly. Choice A is correct as it respects the client's initial sentiment and offers the client the opportunity to ask questions later if needed. Choice B is incorrect as it suggests answering all questions immediately, without considering the client's feelings. Choice C is incorrect as it bypasses the nurse's role in addressing the client's concerns. Choice D, the correct answer, balances respecting the client's wish and ensuring that all questions are appropriately addressed, even if it involves the surgeon returning.

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While working the 11 p.m. to 7 a.m. shift at the long-term care unit, the nurse gathers the nursing staff to listen to the 3 to 11 p.m. intershift report. The nurse notes that a staff member has an odor of alcohol on her breath, slurred speech, and an unsteady gait, suspecting alcohol intoxication. What is the most appropriate action for the nurse to take?

  • A. Contact the nursing supervisor.
  • B. Tell the staff member that she is not allowed to administer medications.
  • C. Ask the staff member how much alcohol she has consumed.
  • D. Ask the staff member to rest in the nurses' lounge until the effects of the alcohol wear off.
Correct Answer: A

Rationale: When a staff member reports to work showing signs of alcohol intoxication, the nurse should objectively note the symptoms and ask a second person to confirm these observations. It is crucial to contact the nursing supervisor immediately. An odor of alcohol, slurred speech, unsteady gait, and errors in judgment are indicators of intoxication, posing a risk to client safety. The staff member should be removed from the client care area. Detailed documentation of the incident is essential, including observations, actions taken, future plans, and the staff member's signature and date on the recorded incident memo. If the staff member refuses to sign, this should be noted by the nurse and a witness. Asking the staff member to rest in the nurses' lounge or restricting medication administration does not ensure client safety, as the staff member could still jeopardize it. Inquiring about the amount of alcohol consumed is confrontational and not relevant to the immediate need of ensuring safety.

A client being treated for sickle cell disease has an order for pain medication. Morphine was ordered, but the nurse is having difficulty deciphering the dose. The nurse should ____.

  • A. ask the attending physician to clarify the order, including the correct medication, dose, route, and frequency
  • B. call the charge nurse to inform the attending physician and verify the order, including the correct medication, dose, route, and frequency
  • C. call the attending physician to verbally verify the order, including the correct medication, dose, route, and frequency
  • D. refrain from administering the medication until the charge nurse can assist in determining the correct dosage
Correct Answer: C

Rationale: In this scenario, when a nurse encounters difficulties in deciphering an order, the appropriate action is to contact the attending physician directly to clarify and verify the medication, dose, route, and frequency. It is crucial for the nurse to have a clear understanding of the order before administering any medication to ensure patient safety and proper treatment. Option A is incorrect as it suggests asking the attending physician to clarify without specifying the urgency of the situation. Option B involves an unnecessary additional step by first contacting the charge nurse before reaching out to the attending physician, potentially delaying the clarification process. Option D is incorrect as it advises refraining from administering the medication, which may not be necessary if the correct dosage can be promptly verified by contacting the attending physician.

An LPN is working on the care plan for a client with diabetes mellitus. Which of these outcomes would be the most appropriate?

  • A. The client will maintain a blood glucose level within the normal range of 70-110 (per facility policy) throughout my shift.
  • B. The client will maintain a blood glucose level within normal range limits today.
  • C. The client will maintain a blood glucose level within the normal range of 70-110 (per facility policy) throughout my shift.
  • D. The client will maintain a blood glucose level within normal limits throughout my shift.
Correct Answer: C

Rationale: The correct answer is 'The client will maintain a blood glucose level within the normal range of 70-110 (per facility policy) throughout my shift.' This outcome is specific, measurable, and aligns with the goal of managing diabetes mellitus. Choice A is correct because it provides a clear target range (70-110) and includes adherence to facility policy, making it precise and goal-oriented. Choice B lacks specificity on the timeframe, and Choice D is vague in defining the target blood glucose range. In nursing care plans, outcomes should be well-defined, achievable, and measurable to effectively monitor the client's progress in managing their condition.

A client asks a nurse about the procedure for becoming an organ donor. The nurse provides the client with which information?

  • A. To speak with the chaplain about the psychosocial aspects of becoming a donor
  • B. That this decision must be made by the next of kin at the time of the client's death
  • C. That anatomic gifts must be made in writing and signed by the client
  • D. To let the health care provider know about the request so that it may be documented in the client's record
Correct Answer: C

Rationale: When a person wishes to become an organ donor, they need to understand that anatomic gifts must be made in writing and signed by the individual. The gift must be made by the donor themselves, typically an individual who is at least 18 years old. If the client is unable to sign, the document should be signed by another person and two witnesses. While speaking to a chaplain or informing the healthcare provider may be part of the process, the essential step is to have a written document signed by the client. Choice A is incorrect as it does not address the procedural aspect of becoming an organ donor. Choice B is incorrect as the decision to make an anatomic gift is typically made by the individual themselves, not the next of kin. Choice D is incorrect as simply informing the healthcare provider is not sufficient for the procedure of becoming an organ donor; a written and signed document by the client is necessary.

Which of the following activities is not part of client advocacy?

  • A. involving the client in treatment and decision-making
  • B. standing up for what is right for the client
  • C. sharing your personal opinions to help provide additional information
  • D. encouraging the client to advocate for themselves
Correct Answer: C

Rationale: The correct answer is 'sharing your personal opinions to help provide additional information.' Client advocacy involves supporting the client's autonomy and choices. It is essential for the nurse to involve the client in treatment and decision-making (Choice A) to ensure their preferences are considered. Standing up for what is right for the client (Choice B) is also a crucial aspect of advocacy, ensuring their rights and well-being are protected. Encouraging the client to advocate for themselves (Choice D) empowers the client to express their needs. However, sharing personal opinions (Choice C) may influence the client's decision-making process and is not a recommended practice in client advocacy, as it can compromise the client's autonomy.