NCLEX NCLEX-PN
Nclex PN Questions and Answers
1. Which of these statements is true regarding advance directives?
- A. They must be reviewed and re-signed every 10 years in order to remain valid.
- B. An advance directive is legally valid in every state, regardless of the state it was created in.
- C. A physician must determine when a client is unable to make medical decisions for themselves.
- D. They cannot be honored by EMTs (emergency medical technicians) unless signed by a doctor.
Correct answer: They cannot be honored by EMTs (emergency medical technicians) unless signed by a doctor.
Rationale: The correct statement is that advance directives cannot be honored by EMTs unless they are signed by a doctor. EMTs are required to provide emergency care to a client, irrespective of their advance directive status, unless the directive has been signed by a doctor. When a client is brought to the hospital, physicians will assess the client and implement the advance directive if necessary. Advance directives do not need to be reviewed and re-signed every 10 years to remain valid; they remain in effect until changed. While advance directives are legally valid in most states, some states may not honor those created in other states, so it's advisable to check the new state's policies if a client moves. Additionally, it typically requires two physicians, not just one, to determine if a client is unable to make medical decisions for themselves.
2. Which of the following scenarios are considered violations of HIPAA laws? Select all that apply.
- A. Discussing discharge plans with a client in a multi-bed recovery room with the curtain drawn around the client’s bed.
- B. Looking up the medical information of a friend not in your care but who gave you permission.
- C. Checking on your spouse’s medical record because you are listed as her power of attorney.
- D. Avoiding conversations about clients while in line in the cafeteria with a mutual caregiver of that client.
Correct answer: B, C
Rationale: Scenarios B and C are considered violations of HIPAA laws. Looking up the medical information of a friend who is not in your care, even with permission, is a violation of HIPAA as the friend is not your patient. Checking on your spouse's medical record, even as a power of attorney, is a violation unless it is directly related to caregiving decisions. Discussing discharge plans with a client in a multi-bed recovery room with the curtain drawn around the client’s bed is not a violation of HIPAA. This scenario is considered an 'incidental disclosure' and is not a breach of HIPAA privacy rules. Avoiding conversations about clients while in line in the cafeteria with a mutual caregiver of that client is actually a good practice as it maintains client confidentiality.
3. 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: The client will maintain a blood glucose level within the normal range of 70–110 (per facility policy) throughout my shift.
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.
4. The LPN notices a client with poor gait and balance. She is currently being treated for hypertension, but the nurse is concerned. What should the nurse do?
- A. Add this issue to the nursing care plan and include daily gait/balance training as an intervention.
- B. Do nothing as this is unrelated to the client's hospitalization.
- C. Speak with the attending physician about the concerns and request a referral for the client to go to physical therapy.
- D. Speak with the attending physician about the concerns and request a referral to physical therapy.
Correct answer: Speak with the attending physician about the concerns and request a referral to physical therapy.
Rationale: Nurses should address any concerns regarding a client's health, even if they are not directly related to the reason for hospitalization. In this case, the nurse noticing the client's poor gait and balance should communicate these concerns to the attending physician. The correct course of action is to request a referral to physical therapy, as this specialized intervention can help address the client's issues effectively. Adding gait/balance training to the care plan without professional assessment and intervention may not be appropriate. Doing nothing is not in line with providing comprehensive care, and referring the client to the hospital gym is not as effective as a referral to physical therapy for addressing gait and balance issues.
5. 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: call the attending physician to verbally verify the order, including the correct medication, dose, route, and frequency
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.
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