NCLEX NCLEX-PN
Next Generation Nclex Questions Overview 3.0 ATI Quizlet
1. What is the most common cause of injury from a house fire?
- A. Explosion
- B. Falls from second-story windows
- C. Thermal damage to skin and body surfaces
- D. Inhalation injury
Correct answer: Inhalation injury
Rationale: Inhalation injury is the most common cause of injury from a house fire. When a fire occurs, the smoke produced contains harmful gases and particles that can be inhaled, leading to serious respiratory issues. This makes inhalation injury the primary concern during a house fire. Choices A, B, and C are less likely to be the primary cause of injury. While explosions may occur in some cases, inhalation of smoke and toxic fumes is generally the most prevalent danger. Falls from windows and thermal damage to the skin are also significant risks but typically occur after inhalation injuries in the sequence of events during a house fire.
2. The patient is inquiring about the use of a PCA pump for pain management. Which statement by the patient indicates a need for additional education?
- A. “I will continue to report my pain score during assessments.”
- B. “I understand that there is a maximum dose per hour that I can receive regardless of how many times I press the button.”
- C. “I believe this new PCA pump will finally alleviate my back pain.”
- D. “I have more control over when and how much medication I receive.”
Correct answer: “I believe this new PCA pump will finally alleviate my back pain.”
Rationale: The correct answer is, “I believe this new PCA pump will finally alleviate my back pain.” This statement indicates a need for additional education as it reflects an unrealistic expectation regarding pain management. It is essential for the patient to understand that while a PCA pump can provide effective pain relief, it may not completely eliminate pain. Option A is correct as it demonstrates the patient's understanding of the importance of reporting pain scores for proper pain management. Option B is correct as it shows the patient's awareness of the maximum dose limits to prevent overdose. Option D is correct as it highlights the patient's understanding of the control they have over their medication administration.
3. When a client is having a seizure and their blood oxygen saturation drops from 92% to 82%, what should the nurse do first?
- A. Open the airway.
- B. Administer oxygen.
- C. Suction the client.
- D. Check for breathing.
Correct answer: Open the airway.
Rationale: When a client is experiencing a seizure and their blood oxygen saturation drops, the priority action for the nurse is to open the airway. Ensuring a clear airway is essential to maintain oxygenation during a seizure episode. Administering oxygen may be necessary but is secondary to ensuring a patent airway. Suctioning the client should only be done if there is an airway obstruction. Checking for breathing is important, but opening the airway takes precedence to support ventilation and oxygenation.
4. A client with sleep apnea has been ordered a CPAP machine. Which action could the RN delegate to a nursing assistant?
- A. Reminding the client to apply the CPAP at bedtime
- B. Obtaining every three-hour oxygen saturation levels
- C. Teaching the client how to turn on the CPAP machine
- D. Assessing for fatigue or depression caused by poor sleep
Correct answer: Reminding the client to apply the CPAP at bedtime
Rationale: The correct answer is reminding the client to apply the CPAP at bedtime. This task can be safely delegated to a nursing assistant as it involves a simple and routine reminder. Option B, obtaining oxygen saturation levels, requires a higher level of training and interpretation of results, making it more appropriate for an RN. Option C, teaching the client how to turn on the CPAP machine, involves educating the client and ensuring proper use of medical equipment, which is within the RN's scope of practice. Option D, assessing for fatigue or depression, requires a comprehensive evaluation that involves interpreting symptoms and identifying underlying causes, making it more suitable for an RN to address.
5. The nurse is caring for a client recovering from a stroke who recently regained consciousness. The client is having difficulty communicating verbally with the team. Which of the following actions would be least appropriate?
- A. Begin client data collection before receiving the physician's order for the referral.
- B. Use documents to provide information for the referral.
- C. Wait for the physician's order for speech therapy before assisting with the appropriate documentation.
- D. Participate in the client referral process.
Correct answer: C: Wait for the physician's order for speech therapy before assisting with the appropriate documentation.
Rationale: In this scenario, the least appropriate action would be to wait for the physician's order for speech therapy before assisting with the appropriate documentation. The nurse should start by collecting client data without needing the physician's order, use documents to provide information for the referral, and actively participate in the client referral process. Waiting for the physician's order unnecessarily delays potentially crucial therapy for the client's recovery, affecting the timeliness and effectiveness of care. Therefore, choice C is the least appropriate as immediate action is required in such situations.
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