NCLEX-PN
2024 Nclex Questions
1. A client reports that someone is in the room and trying to kill him. The nurse's best response is:
- A. "No one is in your room. Let's get you more medicine."?
- B. "I do not see anyone, but you seem to be very frightened."?
- C. "No one can hurt you here."?
- D. "Just tell the person to go away."?
Correct answer: B
Rationale: When a client reports hallucinations or delusions, it is crucial to respond in a non-confrontational and empathetic manner. Choice B acknowledges the client's fear without confirming the delusion, showing understanding, and providing reassurance. This response validates the client's feelings without reinforcing the false belief. The other responses in choices A, C, and D dismiss the client's feelings or perceptions, which can escalate the situation and harm the therapeutic relationship.
2. A 50-milliliter (ml) bolus of normal saline fluid is ordered by the physician. The physician wants it to infuse in 30 minutes. The nurse should set the pump rate at:
- A. 100 ml per hour for one hour.
- B. 60 ml per hour for one-half hour
- C. 120 ml per hour for one hour.
- D. 50 ml per hour for one hour.
Correct answer: A
Rationale: To infuse a 50 ml bolus in 30 minutes, the rate should be calculated as follows: 50 ml / 30 min = 100 ml per hour. Therefore, the correct answer is to set the pump rate at 100 ml per hour for one hour. Choice A is the correct rate based on the calculation. Choices B, C, and D all provide incorrect rates that do not match the physician's order. Choice B would only deliver 30 ml in 30 minutes, not the ordered 50 ml. Choice C would deliver 120 ml in one hour, which is 20 ml more than ordered. Choice D would only provide 25 ml over 30 minutes, not the full 50 ml prescribed.
3. Why might the physician order antibiotics to be given through the central venous access device (CVAD) rather than through a peripheral IV line if the CVAD becomes infected?
- A. To prevent infiltration of the peripheral line
- B. To reduce the pain and discomfort associated with antibiotic administration in a small vein
- C. To lessen the chance of an allergic reaction to the antibiotic
- D. To attempt to eliminate microorganisms in the catheter and prevent having to remove it
Correct answer: D
Rationale: When a patient's central venous access device (CVAD) becomes infected, administering antibiotics through the line is essential to attempt to eliminate microorganisms within the catheter. The goal is to prevent the necessity of removing the catheter, which might be required if the infection persists. Choice A, 'To prevent infiltration of the peripheral line,' is incorrect as the priority is addressing the catheter infection, not preventing issues with a peripheral line. Choice B, 'To reduce the pain and discomfort associated with antibiotic administration in a small vein,' is not relevant to the rationale for choosing the CVAD for antibiotic administration. Choice C, 'To lessen the chance of an allergic reaction to the antibiotic,' is also incorrect as the main focus is managing the catheter-associated infection rather than allergy prevention.
4. Which information obtained from the mother of a child with cerebral palsy most likely correlates to the diagnosis?
- A. She was born at 42 weeks gestation.
- B. She had meningitis when she was 6 months old.
- C. She had physiologic jaundice after delivery.
- D. She has frequent sore throats.
Correct answer: B
Rationale: The diagnosis of meningitis at age 6 months correlates to a diagnosis of cerebral palsy. Cerebral palsy, a neurological disorder, is often associated with birth trauma or infections of the brain or spinal column. Answers A, C, and D are not related to the question. Gestational length (choice A) is not a direct risk factor for cerebral palsy. Physiologic jaundice (choice C) and frequent sore throats (choice D) are not typically associated with cerebral palsy.
5. An elderly client is diagnosed with ovarian cancer. She has surgery followed by chemotherapy with fluorouracil (Adrucil) IV. What should the nurse do if she notices crystals and cloudiness in the IV medication?
- A. Discard the solution and order a new bag
- B. Warm the solution
- C. Continue the infusion and document the finding
- D. Discontinue the medication
Correct answer: A
Rationale: Crystals in the solution are not normal and should not be administered to the client. Discarding the solution and ordering a new bag is the correct action to ensure the client's safety. Warming the solution, as suggested in answer B, will not resolve the issue of crystals and cloudiness, which could potentially harm the client. Continuing the infusion, as in answer C, could pose a risk to the client due to the presence of abnormal substances. Answer D, discontinuing the medication, would typically require a doctor's order and should be done after discarding the contaminated solution.
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