NCLEX-PN
Nclex Exam Cram Practice Questions
1. What is the appropriate intervention for a client who is restrained?
- A. Remove the restraints and provide skin care every hour.
- B. Document the condition of the client's skin every 3 hours.
- C. Assess the restraint every 30 minutes
- D. Tie the restraint to the side rails.
Correct answer: C
Rationale: The correct intervention when a client is restrained is to assess the restraint every 30 minutes. This ensures the safety and well-being of the client by checking for proper fit, circulation, and signs of distress. Removing restraints and providing skin care every hour may not be necessary and could increase the risk of skin breakdown. Documenting the skin condition every 3 hours is important but not the immediate intervention needed when a client is restrained. Tying the restraint to the side rails is unsafe and can cause harm to the client, as restraints should be secured to the bed frame or an immovable part of the bed.
2. While undergoing fetal heart monitoring, a pregnant Native-American woman requests that a medicine woman be present in the examination room. Which of the following is an appropriate response by the nurse?
- A. "I will assist you in arranging to have a medicine woman present."?
- B. "We do not allow medicine women in exam rooms."?
- C. "That does not make any difference in the outcome."?
- D. "It is old-fashioned to believe in that."?
Correct answer: A
Rationale: The correct response is to show cultural awareness and acceptance by offering to assist in arranging for the medicine woman to be present. This demonstrates respect for the client's beliefs and preferences. Choice B is inappropriate as it dismisses the client's request without considering its cultural significance. Choice C is dismissive and does not acknowledge the client's values. Choice D is disrespectful and judgmental, undermining the client's beliefs. Therefore, the only appropriate and professional response is to support the client's request and offer assistance in accommodating it.
3. 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.
4. What information does the healthcare provider remember regarding do-not-resuscitate (DNR) orders in this scenario?
- A. That a DNR order may be written by a healthcare provider
- B. That everything possible must be done if the client stops breathing
- C. That medications only may be given to the client if the client stops breathing
- D. That life support measures will have to be implemented if the client stops breathing
Correct answer: A
Rationale: In a situation where a client has no family members and the client's wife is mentally incompetent, the healthcare provider may write a DNR order if it is deemed medically certain that resuscitation would be futile. A DNR order is a medical directive that instructs healthcare providers not to perform CPR if a patient's heart stops or if the patient stops breathing. Option A is correct because a DNR order can indeed be issued by a healthcare provider under certain circumstances, as it is a medical decision. Options B, C, and D are incorrect as they do not accurately reflect the concept of DNR orders and the decision-making process involved in such situations.
5. A primigravida begins labor when her family is unavailable and she is alone. She is very upset that her family is not with her. Which approach can the nurse take to meet the client's needs at this time?
- A. asking whether another individual wants to be her support person
- B. assuring her that a nursing staff member will be with her at all times
- C. telling her you will try to locate her family
- D. reinforcing the woman's confidence in her own abilities to cope and maintain a sense of control
Correct answer: A
Rationale: In this situation, the best approach for the nurse is to ask whether another individual wants to be the client's support person. This empowers the client to choose someone to be with her until her family can join her, providing the needed support and comfort. Assuring her that a nursing staff member will be with her at all times (Choice B) may not fully address her emotional needs for familiar support. Telling her you will try to locate her family (Choice C) may not be feasible in the immediate situation and may not provide immediate emotional support. While reinforcing the woman's confidence in her own abilities (Choice D) is important, it may not fully address her current need for emotional support and presence of a companion.
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