NCLEX-PN
Nclex PN Questions and Answers
1. The nurse is caring for a non-English speaking client. The surgeon has asked the nurse to hurry up and prepare the client for their scheduled procedure, which is running late. Which of the following is least appropriate?
- A. Explain to the client's family member that the procedure may be delayed further.
- B. Inform the surgeon that the procedure will be delayed further because getting a staff interpreter will take additional time.
- C. Allow the client's family member to serve as the interpreter.
- D. Ask if a phone-service interpreting service is available to expedite the client preparation.
Correct answer: C
Rationale: Allowing the client's family member to serve as the interpreter is the least appropriate option. It is not recommended to rely on family members for interpretation as they may not be impartial, accurate, or trained to handle sensitive medical information. This can lead to misunderstandings, breaches in confidentiality, and compromised care. Choice A is a better option as it involves communication with the family member to manage expectations. Choice B is also appropriate as it prioritizes the need for a professional interpreter to ensure accurate communication. Choice D is a valid option as it explores the possibility of using a phone-service interpreting service to facilitate communication efficiently.
2. A nurse calls a health care provider to question a prescription written for a higher-than-normal dosage of morphine sulfate. The health care provider changes the prescription to a dosage within the normal range, and the nurse documents the new telephone prescription in accordance with the agency's guidelines in the client's record. Which other statement does the nurse document in the nursing notes?
- A. The health care provider made a mistake in the written prescription for morphine sulfate.
- B. An inaccurate dosage of morphine sulfate was prescribed and the health care provider was informed.
- C. The health care provider was contacted to correct a mistake in the dosage of morphine sulfate.
- D. The health care provider was contacted to clarify the prescription for morphine sulfate
Correct answer: D
Rationale: The nurse needs to document a factual, descriptive, and objective statement that does not include words indicating that an individual made a mistake or performed an incorrect action or procedure. If a health care provider's prescription must be questioned, the nurse should record that clarification regarding the prescription was sought. Therefore, the correct statement to document is that the health care provider was contacted to clarify the prescription for morphine sulfate. Choices A, B, and C imply errors or mistakes on the part of the health care provider, which is not the focus of the documentation in this scenario.
3. A client with leukemia is being considered for a bone marrow transplant. The healthcare team is discussing the risks and benefits of this treatment and other possible treatments with the goal of inflicting the least possible harm on the client. Which principle of healthcare ethics is the team practicing?
- A. Fidelity
- B. Nonmaleficence
- C. Autonomy
- D. Justice
Correct answer: B
Rationale: The correct answer is B: Nonmaleficence. Nonmaleficence is the principle of avoiding harm. In healthcare ethics, practitioners aim not only to do good but also to ensure they do no harm. In this scenario, the healthcare team is discussing treatment options with the intention of inflicting the least harm on the client. Choice A, Fidelity, refers to keeping promises made to clients, families, and healthcare professionals. Choice C, Autonomy, pertains to respecting a person's independence and right to make decisions. Choice D, Justice, involves fairness, equity, and the fair allocation of resources, such as healthcare services.
4. An LPN is working on the care plan for a client with diabetes mellitus. Which of these outcomes would be the most appropriate?
- A. The client will maintain a blood glucose level within the normal range of 70-110 (per facility policy) throughout my shift.
- B. The client will maintain a blood glucose level within normal range limits today.
- C. The client will maintain a blood glucose level within the normal range of 70-110 (per facility policy) throughout my shift.
- D. The client will maintain a blood glucose level within normal limits throughout my shift.
Correct answer: C
Rationale: The correct answer is 'The client will maintain a blood glucose level within the normal range of 70-110 (per facility policy) throughout my shift.' This outcome is specific, measurable, and aligns with the goal of managing diabetes mellitus. Choice A is correct because it provides a clear target range (70-110) and includes adherence to facility policy, making it precise and goal-oriented. Choice B lacks specificity on the timeframe, and Choice D is vague in defining the target blood glucose range. In nursing care plans, outcomes should be well-defined, achievable, and measurable to effectively monitor the client's progress in managing their condition.
5. The nurse is caring for a client recovering from a stroke who recently regained consciousness. The client is having difficulty communicating verbally with the team. Which of the following actions would be least appropriate?
- A. Begin client data collection before receiving the physician's order for the referral.
- B. Use documents to provide information for the referral.
- C. Wait for the physician's order for speech therapy before assisting with the appropriate documentation.
- D. Participate in the client referral process.
Correct answer: C
Rationale: In this scenario, the least appropriate action would be to wait for the physician's order for speech therapy before assisting with the appropriate documentation. The nurse should start by collecting client data without needing the physician's order, use documents to provide information for the referral, and actively participate in the client referral process. Waiting for the physician's order unnecessarily delays potentially crucial therapy for the client's recovery, affecting the timeliness and effectiveness of care. Therefore, choice C is the least appropriate as immediate action is required in such situations.
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