NCLEX-PN
Nclex Exam Cram Practice Questions
1. Which of the following statements to the client's family would be appropriate when preparing to provide postmortem care to the client?
- A. "You will not be allowed to see your family member after the postmortem care is performed."?
- B. "I am not able to assist you, but we can call pastoral care if you need any comfort."?
- C. "Unfortunately, we are not allowed to incorporate any cultural practices in my preparations."?
- D. "I will be ensuring that your family member is properly identified before they are transported."?
Correct answer: D
Rationale: The correct statement when preparing to provide postmortem care to the client's family is to assure them that the family member will be properly identified before transportation. This is crucial in ensuring the correct individual is being handled respectfully. Choices A, B, and C are incorrect as they do not address the essential aspect of ensuring the proper identification of the deceased before transportation. It is important to allow the family to see their loved one after postmortem care and, if possible, incorporate any cultural practices. Providing comfort and support to the family during this difficult time is also essential in delivering holistic care.
2. Mrs. Peterson complains of difficulty falling asleep, awakening earlier than desired, and not feeling rested. She attributes these problems to leg pain that is secondary to her arthritis. What is the most appropriate nursing diagnosis for her?
- A. Sleep Pattern Disturbances (related to chronic leg pain)
- B. Fatigue (related to leg pain)
- C. Knowledge Deficit (regarding sleep hygiene measures)
- D. Sleep Pattern Disturbances (related to chronic leg pain)
Correct answer: D
Rationale: The most appropriate nursing diagnosis for Mrs. Peterson is 'Sleep Pattern Disturbances (related to chronic leg pain).' Mrs. Peterson's sleep issues are directly linked to her chronic leg pain, which is a result of her arthritis. This nursing diagnosis addresses the primary cause of her sleep disturbances and allows for interventions that focus on managing the pain to improve her sleep. Choices A, B, and C are incorrect. Choice A correctly identifies the relationship between sleep disturbances and chronic leg pain, addressing the root cause. Choice B is incorrect as it only focuses on fatigue and does not encompass the broader sleep issues. Choice C is not relevant as there is no indication that Mrs. Peterson lacks knowledge about sleep hygiene measures.
3. 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.
4. What should be the first action upon the discovery of an electrical fire?
- A. Disconnect the electrical power if it can be done safely
- B. Smother the source with an object like a blanket
- C. Saturate the source with water or another liquid
- D. Immediately activate the fire alarm
Correct answer: A
Rationale: The correct initial action upon discovering an electrical fire is to disconnect the electrical power if it can be done safely. This helps prevent the fire from spreading through the electrical system. Smothering the fire with a blanket is not recommended for electrical fires as it can fuel the fire. Saturating the source with water or other liquids is also not advised as it can lead to electric shock or spread the fire. Activating the fire alarm is important, but it should be done after disconnecting the power to prevent further escalation of the fire.
5. A client with a closed chest tube drainage system accidentally disconnects the chest tube while being turned by the nurse. What should the nurse do first?
- A. Submerge the end of the chest tube in a bottle of sterile water
- B. Clamp the chest tube with a Kelly clamp
- C. Call the health care provider
- D. Instruct the client to inhale and hold his breath
Correct answer: A
Rationale: When a chest tube becomes disconnected, the priority action is to immediately reattach it to the drainage system or submerge the end in a bottle of sterile water or saline solution to reestablish a water seal. This helps prevent air from entering the pleural space and causing complications. Calling the health care provider is important but not the first action in this emergency. Instructing the client to inhale and hold his breath should be avoided as it can introduce atmospheric air into the pleural space, leading to potential issues. Clamping the chest tube is generally contraindicated, especially in cases of residual air leak or pneumothorax, as it may result in a tension pneumothorax by preventing air from escaping.
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