NCLEX-PN
NCLEX PN Test Bank
1. 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.
2. A licensed practical nurse arrives at work at the long-term care center and is immediately faced with several activities that require attention. Which activity will the nurse attend to first?
- A. Task assignments for the day
- B. Stocking the medication closet
- C. A phone message from employee health services
- D. A phone message from a client's wife
Correct answer: A
Rationale: The nurse's priority should be attending to task assignments for the day. This ensures that client care can begin promptly and efficiently. Stocking the medication closet is important but can be done after ensuring task assignments are clear. Phone messages from employee health services and a client's wife, although important, can be addressed after organizing the staff for client care.
3. A director of nursing at a long-term care center has announced a change to computerized documentation of nursing care. A certified nursing assistant (CNA) on the team, resistant to the change, is not taking an active part in facilitating the implementation of the new procedure. Which strategy would be the best approach to dealing with the conflict?
- A. Meeting with the CNA and encouraging him to express his feelings regarding the change
- B. Ignoring the resistance
- C. Telling the CNA that a licensed practical nurse (LPN) will perform all computer documentation while he documents intake and output and vital signs
- D. Telling the CNA that noncompliance will be documented in the personnel record
Correct answer: A
Rationale: The best approach to dealing with resistance to change is through open communication and understanding. Meeting with the CNA and encouraging him to express his feelings regarding the change allows for a constructive dialogue where issues can be addressed, and alternative solutions can be explored. Ignoring the resistance does not help in resolving the conflict and may lead to further issues. Telling the CNA that a licensed practical nurse (LPN) will perform all computer documentation while he documents intake and output and vital signs does not address the underlying concerns of the CNA and may create more resistance. Threatening the CNA with noncompliance consequences may escalate the resistance and create a negative work environment.
4. A nurse is planning the assignments for the shift. Which task should the nurse assign to the nursing assistant?
- A. Monitoring the vital signs for a client who needs a blood transfusion
- B. Performing hygiene for a client with diarrhea on whom contact precautions have been imposed
- C. Performing a dressing change on a client with a draining abdominal wound that requires frequent dressing changes
- D. Ambulating a client with angina who needs to be ambulated for the first time since admission
Correct answer: B
Rationale: When assigning tasks, a nurse should consider the job description of the nursing assistant, their clinical competence, and state law. Monitoring vital signs for a client needing a blood transfusion, performing a dressing change on a client with a draining wound, and ambulating a client with angina are tasks that require a licensed nurse's skill. On the other hand, providing hygiene care for a client with diarrhea under contact precautions is a task suitable for a nursing assistant. Nursing assistants are trained to provide hygiene care effectively and manage clients under specific precautions, making this task appropriate for them.
5. A client with a spinal cord injury is preparing to return home from the rehabilitation unit. Which of the following statements by a family member indicates a need for further teaching regarding autonomic dysreflexia?
- A. "I should raise him to a sitting position."?
- B. "I should check for a fecal impaction."?
- C. "I should look for a kink in the urinary catheter tubing."?
- D. "I should observe whether symptoms worsen."?
Correct answer: D
Rationale: If the client develops signs or symptoms of autonomic dysreflexia, they need to be addressed immediately. If the family member is not able to relieve them, a healthcare provider needs to be notified immediately. The statement 'I should observe whether symptoms worsen' indicates a passive approach and does not address the urgency of the situation. Choices A, B, and C are correct as they involve active measures to address autonomic dysreflexia, such as raising the client to a sitting position, checking for a fecal impaction, and looking for a kink in the urinary catheter tubing.
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