NCLEX-PN
Nclex Exam Cram Practice Questions
1. The goals of palliative care include all of the following except:
- A. giving clients with life-threatening illnesses the best quality of life possible.
- B. taking care of the whole person"?body, mind, spirit, heart, and soul.
- C. no interventions are needed because the client is near death.
- D. supporting the needs of the family and client.
Correct answer: C
Rationale: The correct goal of palliative care is to provide comprehensive care that addresses the physical, emotional, social, and spiritual needs of the dying client until the end of life. Therefore, the statement 'no interventions are needed because the client is near death' is incorrect as interventions are still essential to ensure comfort and quality of life. Choices A, B, and D are all aligned with the goals of palliative care, focusing on improving the quality of life, providing holistic care, and supporting both the family and the client.
2. The nurse notes that a healthcare provider has documented the following prescription in a client's record: Furosemide (Lasix) 40 mg stat once. What action should the nurse take?
- A. Administering the medication
- B. Drawing up the medication in a syringe
- C. Planning to have the nurse on the next shift administer the medication
- D. Contacting the healthcare provider
Correct answer: D
Rationale: The correct action for the nurse to take in this situation is to contact the healthcare provider. The prescription provided lacks crucial information such as the route of administration. Before administering any medication, the nurse must clarify any missing details with the provider, especially for a stat prescription that requires immediate administration. Drawing up or administering the medication without verifying the route of administration is unsafe and can lead to errors. Planning for the next shift nurse to administer the medication is not appropriate in this scenario as the stat order necessitates immediate action. Therefore, the best course of action is to contact the healthcare provider to obtain clarification on the prescription.
3. What action should the emergency triage nurse take upon receiving the history that a client has a severe cough, fever, night sweats, and body wasting?
- A. Place the client in isolation until further assessment is completed.
- B. Seclude the client from other clients and visitors.
- C. Perform no intervention until test results confirm a diagnosis.
- D. Don personal protective equipment immediately.
Correct answer: B
Rationale: The correct action for the emergency triage nurse to take upon receiving the history that a client has a severe cough, fever, night sweats, and body wasting is to seclude the client from other clients and visitors. These symptoms are suggestive of tuberculosis, a highly infectious disease. By secluding the client, the nurse can prevent the potential spread of the infection to others. Donning personal protective equipment, including gown, gloves, and a mask, is crucial when providing care to the client, but the immediate priority is to prevent the spread of infection by isolating the client. Placing the client in isolation until further assessment is completed ensures that the client is kept away from others until a proper diagnosis and treatment plan can be established, reducing the risk of transmission. Performing no intervention until test results confirm a diagnosis is inappropriate as immediate isolation is necessary in suspected cases of highly infectious diseases like tuberculosis.
4. Which of the following client statements indicates adequate understanding of preparation for electroencephalography?
- A. "I don't need to eat or drink after midnight."?
- B. "I need to wash my hair before the test."?
- C. "I need to remove metal jewelry."?
- D. "I can't take aspirin before the test."?
Correct answer: B
Rationale: The correct statement is, 'I need to wash my hair before the test.' Washing the hair is necessary to remove hair products that could interfere with electrode attachment to the scalp. Restricting food or drink is not required, except for avoiding caffeinated beverages. Removing metal jewelry is unnecessary for an electroencephalography procedure. Aspirin does not need to be avoided before the test; medications like anticonvulsants, tranquilizers, barbiturates, and sedatives are the ones that might need to be held.
5. Which of these types of fluid output is not typically measured?
- A. chest tube drainage
- B. emesis
- C. evaporative water from the respiratory tract
- D. urine
Correct answer: D
Rationale: The correct answer is 'urine.' Urine output is routinely measured to assess renal function and fluid balance. Choices A, B, and C are types of fluid output that are typically measured in a clinical setting. Chest tube drainage is monitored to evaluate drainage from the chest cavity, emesis refers to vomitus which can indicate gastrointestinal issues, and evaporative water from the respiratory tract is considered insensible loss and is not directly measured but estimated in overall fluid balance assessments.
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