NCLEX-PN
Nclex PN Questions and Answers
1. Which action exemplifies the use of evidence-based practice in the delivery of client care?
- A. Advising a client to agree to the treatment recommended by their healthcare provider
- B. Taking a rectal temperature from a client for whom bleeding precautions have been instituted
- C. Donning sterile gloves to change an abdominal wound dressing
- D. Encouraging a client to take an herbal substance to treat their insomnia
Correct answer: C
Rationale: Evidence-based practice is an approach to client care where the nurse integrates the client’s preferences, clinical expertise, and the best research evidence to deliver quality care. Donning sterile gloves to change an abdominal wound dressing exemplifies evidence-based practice as it prevents the entrance of harmful bacteria into the wound, following best practice guidelines. The other options do not align with evidence-based practice. Advising a client to agree to a treatment does not involve integrating research evidence. Taking herbal substances may not be supported by strong research evidence and can pose risks. Additionally, rectal temperature-taking in a client with bleeding precautions can increase the risk of injury to the rectal mucosa, not aligning with best practices in care delivery.
2. The nurse is working the same shift two days in a row. On the first of these days, while caring for one assigned client, the client says, "Will you promise me you will be my nurse tomorrow?"? Which response is most appropriate?
- A. "Yes, I promise you I will be your nurse during my shift tomorrow."?
- B. "You will need to speak to my supervisor about this request."?
- C. "While I cannot promise that I will be your nurse tomorrow, I can talk to the charge nurse about this request."?
- D. "Because of confidentiality, I cannot discuss tomorrow's assignments with you."?
Correct answer: D
Rationale: The most appropriate response is to maintain confidentiality regarding work assignments. It is crucial to uphold patient privacy and not disclose information about staff schedules or assignments. Choices A, B, and C involve promising or redirecting the patient, which is not suitable in this situation. Choice D respects confidentiality and is the most professional response in this scenario.
3. An example of a process standard on a med-surg unit is:
- A. a procedure for changing IV tubing.
- B. a policy for staffing.
- C. the job description of the CEO (chief executive officer).
- D. a procedure for checking waveforms on a client being treated with an intra-aortic balloon pump.
Correct answer: D
Rationale: Process standards define the actions and behaviors required by staff to provide care on a med-surg unit. A procedure for changing IV tubing is a critical psychomotor skill necessary for safe and effective patient care in this setting. Choice B, a policy for staffing, pertains more to organizational management rather than specific care processes on the unit. Choice C, the job description of the CEO, delineates the responsibilities of the organization's top executive and is not a process standard for frontline staff. Choice D, a procedure for checking waveforms on a client with an intra-aortic balloon pump, is more specific to a cardiac care unit and not typically performed on a med-surg unit.
4. The nurse is caring for a client awaiting test results on a biopsy. The client is unconscious, and the physician informs the client's spouse that the biopsy came back positive for cancer. The spouse asks the nurse if they will not share this news with the client because they would prefer the client be unaware of the diagnosis. Which of the following responses is most appropriate?
- A. "I will have a psychiatrist confirm whether the news will cause negative effects, and if so, I will comply with your request."?
- B. "For ethical reasons, I am unable to withhold this information from the client."?
- C. "You do not have the option to sign paperwork stating you are accepting the risk of not sharing this with the client."?
- D. "You must have a durable power of attorney for healthcare advanced directive in place before I can consider this request."?
Correct answer: B
Rationale: The correct response is, "For ethical reasons, I am unable to withhold this information from the client."? The ethical principle of veracity requires that the nurse is truthful with the client and does not withhold information even if it is requested by the family. Choice A is incorrect because seeking a psychiatrist's confirmation is not necessary to uphold the ethical principle of truth-telling. Choice C is incorrect as implying that signing paperwork overrides the nurse's ethical obligation to be honest with the client is inappropriate. Choice D is also incorrect as a durable power of attorney is not relevant in this situation where the spouse is asking the nurse to withhold information.
5. The nurse in the emergency room is admitting a client who has sustained a gunshot wound and will require immediate surgery. The client is unconscious and by themselves. Which of the following actions is most appropriate?
- A. Call the charge nurse and request that the facility's legal counsel provide a waiver for informed consent.
- B. Attempt to stabilize the client in the emergency room until they are conscious enough to provide informed consent.
- C. Try to locate the client's family to obtain informed consent before transporting the client to the operating room.
- D. Proceed with transporting the client to the operating room without obtaining informed consent.
Correct answer: D
Rationale: In emergency situations where a client is unconscious and requires immediate surgery to save their life, the priority is to proceed with necessary interventions without delay to ensure the best possible outcome. Obtaining informed consent is essential in healthcare, but in situations where a delay in treatment can be life-threatening, healthcare providers are ethically and legally permitted to proceed with treatment without consent. Attempting to stabilize the client until conscious enough to provide consent or trying to locate family members for consent would cause a dangerous delay in critical care. Therefore, the most appropriate action in this scenario is to transport the unconscious client to the operating room for immediate surgery.
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