NCLEX NCLEX-PN
2024 Nclex Questions
1. Activities of effective supervisors can be task-related or people-related activities. An example of a task-related supervisory activity is:
- A. coaching.
- B. evaluating.
- C. delegating.
- D. facilitating.
Correct answer: delegating.
Rationale: Delegating is the act of assigning work to those capable and competent to do the work, making it a task-related supervisory activity. Coaching, evaluating, and facilitating are people-related supervisory activities. Coaching involves guiding and developing individuals, evaluating entails assessing performance, and facilitating focuses on enabling tasks and processes. These activities are more centered on interacting with and supporting people rather than directly assigning tasks. Therefore, in the context of task-related activities, delegating stands out as the correct choice.
2. A case manager is reviewing the records of the clients in the nursing unit. Which note(s) in a client’s record indicate an unexpected outcome and the need for follow-up?
- A. A client is performing their own colostomy irrigations.
- B. A client with a central venous catheter has a temperature of 100.6°F.
- C. A client who has just undergone surgery has a urine output of more than 30 mL/hr.
- D. A client with a new diagnosis of diabetes mellitus is self-administering insulin.
Correct answer: A client with a central venous catheter has a temperature of 100.6°F.
Rationale: A case manager is a healthcare professional responsible for coordinating a client's care from admission through and after discharge. They evaluate and update the plan of care as needed, monitoring for unexpected outcomes and providing follow-up. A temperature of 100.6°F in a client with a central venous catheter is an unexpected outcome that requires follow-up due to the potential indication of an infection. Choices A, C, and D describe expected outcomes and appropriate self-care management. The client self-irrigating their colostomy, a post-surgical client having adequate urine output, and a newly diagnosed diabetic self-administering insulin are all positive indicators of self-care and expected outcomes, not requiring immediate follow-up.
3. A woman is in the active phase of labor. An external monitor has been applied, and a fetal heart deceleration of uniform shape is observed, beginning just as the contraction is underway and returning to the baseline at the end of the contraction. Which of the following nursing actions is most appropriate?
- A. Administer O2.
- B. Turn the client on her left side.
- C. Notify the physician.
- D. No action is necessary
Correct answer: No action is necessary
Rationale: This scenario describes early deceleration due to head compression, which is a benign finding in labor. Early decelerations mirror the contractions and do not require any intervention as they are considered a normal response to fetal head compression. The fetal heart rate returns to baseline at the end of the contraction. In this case, the correct action is no action at the moment. Close monitoring of the mother and baby is essential, but immediate intervention is not required. Administering O2 (Choice A) or turning the client on her left side (Choice B) is not indicated for early decelerations. Notifying the physician (Choice C) is unnecessary for this type of deceleration.
4. During a report from an ER nurse about a client, the nurse identifies a statement that requires additional follow-up. Which of the following statements needs further clarification?
- A. “The client said they have been taking aspirin, but I’m not sure for how long or how much.”
- B. “The client frequently takes antacids, but they have not taken any in the last three days.”
- C. “The client stopped taking ibuprofen after developing gastric ulcers.”
- D. “The client takes Antabuse and has stopped using mouthwash.”
Correct answer: “The client said they have been taking aspirin, but I’m not sure for how long or how much.”
Rationale: The correct answer requires further follow-up as the nurse needs to know the duration and dosage of aspirin since it can impact the patient’s bleeding risk. Choice B does not require immediate follow-up as not taking antacids for three days is not critical. Choice C indicates a necessary decision made by the client to stop ibuprofen after developing gastric ulcers, hence no immediate follow-up is needed. Choice D provides important information, but the priority is to address the lack of specificity regarding the client's aspirin use, which is crucial for assessing bleeding risk and potential interactions.
5. A 4-year-old client is unable to go to sleep at night in the hospital. Which nursing intervention best promotes sleep for the child?
- A. turning out the room light and closing the door
- B. tiring the child during the evening with quiet activities
- C. identifying the child’s home bedtime rituals and following them
- D. encouraging visitation by friends during the evening
Correct answer: identifying the child’s home bedtime rituals and following them
Rationale: For a 4-year-old client struggling to sleep in the hospital, it is essential to identify and replicate their home bedtime rituals. This familiarity can provide comfort and promote better sleep. Turning out the room light and closing the door (Choice A) might increase the child's fear by plunging the room into darkness, making it an incorrect choice. Tiring the child with quiet activities (Choice B) is incorrect as it may stimulate rather than calm the child. Encouraging visitation by friends (Choice D) can lead to increased excitement, hindering the child's ability to fall asleep instead of promoting a restful environment.
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