NCLEX-PN
Nclex Exam Cram Practice Questions
1. An 85-year-old client is eligible for Medicare-reimbursable home care services. Referral is contingent on meeting which of the following criteria?
- A. homebound status, requiring skilled therapy care
- B. immediate previous hospitalization for acute care
- C. age
- D. requirement of nursing and social work support
Correct answer: A
Rationale: The correct criteria for Medicare-reimbursable home care services include the client being homebound and requiring a skilled service, such as physical therapy, occupational therapy, speech therapy, nursing, or social work. Choice A is correct because it aligns with these requirements. Choice B is incorrect as immediate previous hospitalization is not a prerequisite for home care services. Choice C is incorrect as age alone does not determine eligibility for Medicare-reimbursable home care services. Choice D is incorrect as the requirement of nursing and social work support alone is not sufficient for Medicare-reimbursable home care services.
2. A client whose right leg is in skeletal traction complains of pain in the leg. Which action should the nurse take first?
- A. Asking the client to wiggle their toes
- B. Medicating the client with the prescribed analgesic
- C. Realigning the client
- D. Removing some of the traction weights
Correct answer: C
Rationale: When a client in skeletal traction complains of pain, the priority action for the nurse is to realign the client. Severe pain may indicate the need for realignment or that the traction weights are too heavy. Realigning the client should be the initial response as it can help alleviate the pain by ensuring proper alignment. Asking the client to wiggle their toes may not address the underlying issue causing the pain. Removing traction weights should never be done unless specifically ordered by the healthcare provider as it can affect the traction's effectiveness. Medicating the client with analgesics should only be considered after attempting to address the cause of the pain, which in this case, is realignment.
3. Which of the following indicates a hazard for a client on oxygen therapy?
- A. A 'No Smoking' sign is on the door.
- B. The client is wearing a synthetic gown.
- C. Electrical equipment is grounded.
- D. Matches are removed.
Correct answer: B
Rationale: The correct answer is that the client is wearing a synthetic gown. A synthetic gown might generate sparks of static electricity, which can be a fire hazard, especially in the presence of oxygen. Clients on oxygen therapy should wear cotton gowns to minimize the risk of fire. The other options are not hazards for a client on oxygen therapy: having a 'No Smoking' sign on the door promotes safety by preventing smoking, ensuring electrical equipment is grounded reduces the risk of electrical hazards, and removing matches decreases the risk of fire hazards.
4. Why is client and family communication and education concerning restraints essential?
- A. confuses both groups further
- B. helps with coping and stress levels
- C. encourages cooperation with the client and family
- D. puts the responsibility on the client and family, not the nurse
Correct answer: C
Rationale: Client and family communication and education concerning restraints are essential to encourage cooperation. When the client and family understand the purpose and expected benefits of restraints, they are more likely to cooperate. This understanding can help prevent well-meaning family members from releasing restraints due to confusion or lack of information. Therefore, choice C is correct. Choices A, B, and D are incorrect because confusing both groups further, helping with coping and stress levels, and shifting responsibility to the client and family are not the primary goals of communication and education concerning restraints.
5. 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.
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