NCLEX NCLEX-PN
2024 Nclex Questions
1. Referral for client education in the community can be accomplished through all of the following except:
- A. community agencies such as the American Heart Association
- B. parish nurses
- C. home health care agencies
- D. unlicensed massage therapists
Correct answer: unlicensed massage therapists
Rationale: Client education should be conducted by individuals with acknowledged expertise in the subject area and appropriate credentials to support their activities within the healthcare community. Choices A, B, and C involve reputable entities or professionals who can provide accurate and reliable client education. The American Heart Association, parish nurses, and home health care agencies are recognized for their healthcare-related knowledge and qualifications. However, unlicensed massage therapists lack the necessary qualifications and expertise to deliver appropriate healthcare-related education, making them unsuitable for referrals when it comes to client education in the community.
2. During the history assessment of an 80-year-old client, which statement made by the client might indicate a possible fluid and electrolyte imbalance?
- A. “My skin is always so dry.”
- B. “I often use a laxative for constipation.”
- C. “I have always liked to drink a lot of iced tea.”
- D. “I sometimes have a problem with dribbling urine.”
Correct answer: “I often use a laxative for constipation.”
Rationale: The correct answer is "I often use a laxative for constipation." Frequent use of laxatives can lead to diarrhea and electrolyte loss, indicating a possible fluid and electrolyte imbalance. Statements A, C, and D are not directly related to fluid and electrolyte imbalance. Statement A about dry skin may suggest dehydration, but it is less specific to electrolyte imbalance than the frequent use of laxatives. Statement C about drinking a lot of iced tea could potentially relate to fluid intake, but it doesn't directly indicate an imbalance. Statement D about dribbling urine is more indicative of a potential urinary issue rather than a fluid and electrolyte imbalance.
3. How far should the enema tube be inserted for a client to have a flatus-reducing enema?
- A. 4 inches.
- B. 6 inches.
- C. 2 inches.
- D. 8 inches.
Correct answer: 4 inches.
Rationale: The correct answer is to insert the enema tube 4 inches. Enema tubing must be passed beyond the internal sphincter, which is typically around 4 inches in an adult. Inserting the tube only 2 inches is not far enough to reach this point. On the other hand, inserting the tube 6 or 8 inches is too far and might cause trauma to the bowel, which is unnecessary for a flatus-reducing enema. Therefore, the correct insertion depth of the enema tube is crucial to ensure effectiveness and safety in providing the intended treatment.
4. The nurse observes bilateral bruises on the arms of an elderly client in a long-term care facility. Which of the following questions should the nurse ask this client?
- A. “How did you get those bruises?”
- B. “Did someone grab you by your arms?”
- C. “Do you fall often?”
- D. “What did you bump against?”
Correct answer: “Did someone grab you by your arms?”
Rationale: The correct answer is asking, “Did someone grab you by your arms?” This question is direct and addresses the possibility of abuse, which is crucial when dealing with suspected abuse cases. It is important to ask direct questions in a sensitive and non-accusatory manner to gather information. Choice A is too general and may not prompt a disclosure of abuse. Choice C assumes falling as the cause without addressing abuse directly. Choice D is vague and does not specifically inquire about potential abuse, making it less effective in identifying abuse cases compared to the correct choice.
5. A Roman Catholic client is preparing to have magnetic resonance imaging. He wants to wear his metal crucifix pendant while he is receiving the test. Which of the following is an appropriate response by the nurse?
- A. “Because it gives you comfort, you may wear it.”
- B. “It is a violation of religious rights to forbid it.”
- C. “I am sorry, but it is not safe for you to wear the crucifix during this test.”
- D. “You may wear it because it is important to you.”
Correct answer: “I am sorry, but it is not safe for you to wear the crucifix during this test.”
Rationale: No metal objects may be worn while receiving magnetic resonance imaging due to safety risks involved with the strong magnet. The correct response by the nurse should prioritize the safety of the client. Allowing the client to wear the metal crucifix poses a risk of injury or interference with the imaging process. Option A is not appropriate as safety takes precedence over comfort in this situation. Option B is incorrect as it does not address the safety concerns associated with wearing metal objects during an MRI. Option D is also incorrect as it fails to acknowledge the safety issue involved and instead focuses solely on the importance to the client. It is important for the nurse to offer alternative forms of spiritual support that do not pose a risk during the MRI procedure.
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