NCLEX NCLEX-PN
Nclex PN Questions and Answers
1. Which of the following activities is not part of client advocacy?
- A. involving the client in treatment and decision-making
- B. standing up for what is right for the client
- C. sharing your personal opinions to help provide additional information
- D. encouraging the client to advocate for themselves
Correct answer: sharing your personal opinions to help provide additional information
Rationale: The correct answer is 'sharing your personal opinions to help provide additional information.' Client advocacy involves supporting the client's autonomy and choices. It is essential for the nurse to involve the client in treatment and decision-making (Choice A) to ensure their preferences are considered. Standing up for what is right for the client (Choice B) is also a crucial aspect of advocacy, ensuring their rights and well-being are protected. Encouraging the client to advocate for themselves (Choice D) empowers the client to express their needs. However, sharing personal opinions (Choice C) may influence the client's decision-making process and is not a recommended practice in client advocacy, as it can compromise the client's autonomy.
2. A physician orders a serum creatinine for a hospitalized client. The nurse should explain to the client and his family that this test:
- A. is normal if the level is 4.0 to 5.5 mg/dl.
- B. can be elevated with increased protein intake.
- C. is a better indicator of renal function than the BUN.
- D. reflects the fluid volume status of a person
Correct answer: is a better indicator of renal function than the BUN.
Rationale: A serum creatinine level should be 0.7 to 1.5 mg/dl, and it does not vary with increased protein intake, so it is a better indicator of renal function than the BUN. Choice A is incorrect as a serum creatinine level of 4.0 to 5.5 mg/dl is not normal. Choice B is incorrect as serum creatinine is not affected by increased protein intake. Choice D is incorrect as serum creatinine primarily reflects renal function, not fluid volume status.
3. Why must the nurse be careful not to cut through or disrupt any tears, holes, bloodstains, or dirt present on the clothing of a client who has experienced trauma?
- A. The clothing is the property of another and must be treated with care.
- B. Such care facilitates repair and salvage of the clothing.
- C. The clothing of a trauma victim is potential evidence with legal implications.
- D. Such care decreases trauma to the family members receiving the clothing.
Correct answer: The clothing of a trauma victim is potential evidence with legal implications.
Rationale: The correct answer is C. Trauma in any client, living or dead, has potential legal and/or forensic implications. Clothing, patterns of stains, and debris are sources of potential evidence and must be preserved. Nurses must be aware of state and local regulations that require mandatory reporting of cases of suspected child and elder abuse, accidental death, and suicide. Each Emergency Department has written policies and procedures to assist nurses and other health care providers in making appropriate reports. Physical evidence is real, tangible, or latent matter that can be visualized, measured, or analyzed. Emergency Department nurses can be called on to collect evidence. Health care facilities have policies governing the collection of forensic evidence. The chain of evidence custody must be followed to ensure the integrity and credibility of the evidence. The chain of evidence custody is the pathway that evidence follows from the time it is collected until it has served its purpose in the legal investigation of an incident. Choices A, B, and D are incorrect because they do not address the crucial aspect of preserving potential evidence with legal implications that may be present on the clothing of a trauma victim.
4. To ensure proper immobilization and increase client comfort when using a rigid splint, what should be done?
- A. Place the client on a stretcher before splinting.
- B. Place the client on a long spine board before splinting.
- C. Pad the spaces between the body part and the splint.
- D. Ensure that the splint conforms to the body curves.
Correct answer: Pad the spaces between the body part and the splint.
Rationale: Correct. When using a rigid splint, it is essential to pad the spaces between the body part and the splint to ensure proper immobilization and increase client comfort. This padding helps prevent pressure points and ensures a proper fit of the splint without causing discomfort. Placing the client on a stretcher or a long spine board before splinting (choices A and B) may be necessary for transportation but does not directly relate to the proper use of a rigid splint. Ensuring that the splint conforms to the body curves (choice D) is important but not as crucial as padding the spaces to prevent discomfort and ensure proper immobilization.
5. Social support systems include all of the following except:
- A. call-in help lines
- B. emotional assistance provided by others
- C. community support groups
- D. use of coping skills and verbalization for anger management
Correct answer: use of coping skills and verbalization for anger management
Rationale: The correct answer is the use of coping skills and verbalization for anger management. Social support systems involve external sources of support from others or the community. Call-in help lines, emotional assistance provided by others, and community support groups all represent social support systems where individuals can seek help and assistance from outside sources. On the other hand, the use of coping skills and verbalization for anger management refers to individual strategies rather than external social support.
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