NCLEX-PN
NCLEX PN Test Bank
1. A nurse in charge of a long-term care facility who is working with a nursing assistant on the night shift prepares to take a break. To ensure client safety during the break, which actions should the nurse take? Select all that apply.
- A. Asking the nursing assistant to contact the health care provider during the nurse’s break if a client’s pain medication is not effective
- B. Informing the nursing assistant that she is leaving the nursing unit to get a cup of coffee from a vending machine in the lobby
- C. Asking the nursing assistant to administer a medication placed at the client's bedside if the client awakens
- D. Conducting client rounds before taking the break
Correct answer: D
Rationale: The nurse is responsible for ensuring client safety at all times and must not leave the nursing unit for any reason during the shift. The nurse’s break should be taken in a designated area located on the nursing unit. Before taking the break, the nurse should check all clients to ensure that they are safe and comfortable and that their needs have been met. Conducting client rounds before taking the break is crucial to assess the clients' conditions and address any immediate needs, ensuring their safety. Asking the nursing assistant to contact the health care provider during the nurse’s break is not appropriate as the nurse should handle this responsibility. Leaving the nursing unit to get coffee is not recommended as the nurse should stay within the unit to respond promptly to any client needs. Asking the nursing assistant to administer medication or make clinical decisions is outside the scope of their practice and should not be delegated.
2. The nurse belongs to a professional nursing organization that provides social, educational, and political venues for nurses. The nurse has been active in this organization for almost two years, during which time she meets and works with nurses from several different nursing agencies and health care institutions to achieve a variety of goals, including obtaining advice regarding a personal career choice. This is an example of:
- A. professional nurturing.
- B. networking.
- C. mentoring.
- D. collegiality.
Correct answer: B
Rationale: Networking involves the process of developing and using contacts throughout one's professional career for information, advice, and support. In this scenario, the nurse is actively engaging with other professionals from various institutions to achieve common goals and seek career advice, which aligns with the concept of networking. Professional nurturing and mentoring focus on providing support and guidance to colleagues, while collegiality refers to the camaraderie and rapport established among individuals through shared experiences, which is not the primary focus of the nurse's interaction in the given situation.
3. In a disaster situation, the nurse assessing a diabetic client on insulin assesses for all of the following except:
- A. diabetic signs and symptoms.
- B. nutritional status.
- C. bleeding problems.
- D. availability of insulin.
Correct answer: C
Rationale: In a disaster situation, when assessing a diabetic client on insulin, the nurse should assess for diabetic signs and symptoms to monitor the client's condition, nutritional status to ensure proper dietary management, and availability of insulin to maintain the client's medication regimen. Bleeding problems are not directly related to diabetes or insulin use, making it the exception in this assessment scenario. Therefore, bleeding problems would not be a typical focus of assessment in this context.
4. The nurse should teach parents of small children that the most common type of first-degree burn is:
- A. scalding from hot bath water or spills
- B. contact with hot surfaces such as stoves and fireplaces
- C. contact with flammable liquids or gases resulting in flash burns
- D. sunburn from lack of protection and overexposure
Correct answer: D
Rationale: The most common type of first-degree burn in small children is sunburn, often due to lack of protection and overexposure to the sun. This type of burn highlights the importance of educating parents about using sunscreens and ensuring children are adequately protected from the sun's harmful rays. Choices A, B, and C describe scenarios that can lead to burns but are not the most common type of first-degree burn in small children, making them incorrect.
5. A client with diabetes mellitus who takes a daily dose of NPH insulin has a hard time drawing the insulin into a syringe because he has difficulty seeing the markings on the syringe. To which services does the nurse suggest a referral?
- A. Home care
- B. Occupational therapy
- C. Social services
- D. Physical therapy
Correct answer: B
Rationale: For a client with diabetes mellitus who struggles to draw insulin due to poor vision, the nurse should suggest a referral to home care services. Home care provides various support services, including assistance with insulin administration. In this scenario, a home care nurse can prefill a week's supply of syringes with the correct insulin dose for the client. These syringes can be stored in the client's refrigerator for self-administration. Occupational therapy focuses on helping individuals with activities of daily living, such as using adaptive devices. Social services typically address counseling and financial aspects of care. Physical therapy is geared towards treating physical disabilities or impairments through exercises and techniques.
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