NCLEX-PN
Nclex Exam Cram Practice Questions
1. The nurse teaching a client about hepatitis and its transmission should explain that one type of hepatitis does not produce a carrier state after its acute phase. Which type is it?
- A. hepatitis A
- B. hepatitis B
- C. hepatitis C
- D. hepatitis D
Correct answer: A
Rationale: The correct answer is hepatitis A. Hepatitis A does not produce a carrier state after its acute phase. It is transmitted via contaminated water or food through the oral-fecal route and is not blood-borne. Hepatitis B, choice B, can lead to a carrier state where the person remains infectious despite being asymptomatic. Hepatitis C, choice C, can also result in a chronic carrier state. Hepatitis D, choice D, is an incomplete virus that requires hepatitis B to replicate; it does not lead to a carrier state on its own.
2. A nurse is performing suctioning through an adult client's tracheostomy tube. The nurse notes that the client's oxygen saturation is 89% and terminates the procedure. Which action would the nurse take next?
- A. Rechecking the pulse oximetry reading
- B. Calling the respiratory therapist
- C. Calling the healthcare provider
- D. Oxygenating the client with 100% oxygen
Correct answer: D
Rationale: The nurse should monitor the client's heart rate and pulse oximetry during suctioning to assess the client's tolerance of the procedure. Oxygen desaturation to below 90% indicates hypoxemia. If hypoxia occurs during suctioning, the nurse must terminate the procedure and oxygenate the client with 100% oxygen to address the hypoxemia promptly and ensure the client's safety. Rechecking the pulse oximetry reading is important, but the priority is to address the hypoxemia by providing oxygen. Contacting the healthcare provider or respiratory therapist is not necessary at this time as the nurse can manage the hypoxemia with oxygenation. Oxygenating the client with 100% oxygen is the immediate action required in this situation.
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. A nurse is reviewing the notes written by a nurse on a previous shift. Which note in the client's record reflects the correct use of guidelines for documentation?
- A. The client's wound is healing well.
- B. The client seems anxious.
- C. The client's intake was 360 mL
- D. The client is voiding large amounts
Correct answer: C
Rationale: Quality documentation and reporting require information to be factual, accurate, complete, current, and organized. Choice C, 'The client's intake was 360 mL,' reflects the correct use of guidelines for documentation as it provides a specific and measurable observation. This note meets the criteria for quality documentation by being specific and quantifiable. Choices A, B, and D lack specificity and quantifiability. Choice A includes a subjective term 'well,' choice B uses 'seems' indicating uncertainty, and choice D uses a vague term 'large' without quantifying the amount.
5. Which of the following syndromes associated with incomplete lesions of the spinal cord results from damage to one-half of the spinal cord?
- A. Brown-S�quard syndrome
- B. posterior cord syndrome
- C. central cord syndrome
- D. cauda equina syndrome
Correct answer: A
Rationale: Brown-S�quard syndrome is indeed associated with incomplete lesions of the spinal cord, and it specifically results from damage to one-half of the spinal cord. This syndrome manifests as ipsilateral motor paralysis, ipsilateral loss of vibration and proprioception, and contralateral loss of pain and temperature sensation. Posterior cord syndrome mainly involves the loss of proprioception and vibratory sense, while sparing motor function and pain sensation. Central cord syndrome typically presents with more weakness in the upper extremities compared to the lower extremities due to central spinal cord damage. Cauda equina syndrome affects the nerve roots at the level of the conus medullaris, leading to symptoms like lower extremity weakness, numbness, and bowel/bladder dysfunction.
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