Nclex Exam Cram Practice Questions

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When a 17-year-old client arrives at the clinic suspecting a sexually transmitted infection, what information does the nurse provide concerning informed consent?

  • A. She will need to sign an informed consent form.
  • B. Her mother or father will need to be contacted for permission to treat her.
  • C. A consent form is not needed if the problem is a sexually transmitted infection.
  • D. Anyone over the age of 18 years may sign a consent form for her treatment.
Correct Answer: A

Rationale: Informed consent is a person's agreement to allow something, such as a treatment, to be performed. A consent form is required even if the problem is a sexually transmitted infection. If the client is a minor, the minor may sign the informed consent form in specific situations, including seeking treatment for a sexually transmitted infection. In this case, the 17-year-old client is seeking examination and treatment for a sexually transmitted infection, so she will need to sign the informed consent form. Contacting her parents for permission is not required in this situation. Choice C is incorrect because a consent form is necessary regardless of the medical issue. Choice D is incorrect because the individual's age is not the determining factor; rather, it is the nature of the medical service being sought that dictates the need for informed consent.

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When providing perineal care to a female client, how should the nurse perform the procedure?

  • A. with gloves, washing the perineal area from front to back
  • B. without gloves, having the client perform all care
  • C. with gloves, washing the perineal area from back to front
  • D. without gloves, pouring water from a sterile bottle
Correct Answer: A

Rationale: When providing perineal care to a female client, the nurse should wear gloves and wash the perineal area from front to back. This technique helps prevent the introduction of E. coli and other bacteria into the urethra, reducing the risk of urinary tract infections. Washing from back to front can introduce bacteria from the anal area to the urethra, leading to infections. Performing the procedure without gloves or having the client perform all care does not adhere to infection control practices. Pouring water from a sterile bottle alone may not ensure proper cleansing and infection prevention. Therefore, choices B, C, and D are incorrect as they do not follow proper perineal care guidelines.

What condition is mammography used to detect?

  • A. pain
  • B. tumor
  • C. edema
  • D. epilepsy
Correct Answer: B

Rationale: Mammography is specifically used to detect tumors or abnormal growths, especially in breast tissue. It is not a tool for identifying pain, edema, or epilepsy. Therefore, the correct answer is 'tumor.' Pain is a symptom, edema is swelling, and epilepsy is a neurological disorder; none of these are conditions typically detected through mammography.

The nurse is teaching a client about sleep and gives background information on normal sleep patterns. Which of the following substances promotes sleep?

  • A. serotonin
  • B. cortisol
  • C. alcohol
  • D. narcotics
Correct Answer: A

Rationale: Serotonin is a substance found in the body that promotes sleep. It plays a role in the synthesis of a hypnogenic factor that directly induces sleep. Cortisol is a stress hormone that can disrupt sleep patterns. Alcohol can disrupt REM sleep and negatively impact sleep quality. Narcotics, like alcohol, can interfere with sleep architecture and lead to poor quality sleep. Therefore, the correct answer is serotonin as it is associated with promoting sleep, while the other substances listed can have negative effects on sleep patterns.

Which of the following is not considered one of the five rights of medication administration?

  • A. client
  • B. drug
  • C. dose
  • D. routine
Correct Answer: D

Rationale: The five rights of medication administration are dose, client, drug, route, and time. The correct answer is 'routine' as it is not commonly recognized as one of the essential rights in medication administration. Choice A, client, is necessary to ensure the right medication is administered to the right individual. Choice B, drug, is crucial to confirm the correct medication is given. Choice C, dose, is essential to ensure the right amount of medication is administered. Choice D, routine, is not typically included in the five rights of medication administration and is therefore the correct answer.

The nurse is preparing to administer IV Vancomycin to a client. Which of the following nursing actions should be taken first?

  • A. Performing a physical assessment prior to administration
  • B. Obtaining the most recent lab values regarding renal function
  • C. Reviewing peaks and troughs for the past few days
  • D. Ensuring the client is not allergic to the medication
Correct Answer: D

Rationale: Before administering any medication, including IV Vancomycin, it is crucial to ensure that the client is not allergic to the medication. This is the most critical action to prevent any potential allergic reactions. While performing a physical assessment is important, it may not be as time-sensitive as checking for allergies. Obtaining lab values related to renal function is also significant with Vancomycin due to its potential nephrotoxicity, but ensuring the client's safety by checking for allergies takes precedence. Reviewing peaks and troughs is important for monitoring drug levels, but it is a secondary step compared to checking for allergies prior to administration.

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