NCLEX NCLEX-PN
Psychosocial Integrity Nclex PN Questions
1. Who may legally give informed consent?
- A. an 86-year-old male with advanced Alzheimer’s disease
- B. a 14-year-old girl needing an appendectomy who is not an emancipated minor
- C. a 14-year-old girl needing an appendectomy who is not an emancipated minor
- D. a 6-month-old baby needing bowel surgery
Correct answer: a 14-year-old girl needing an appendectomy who is not an emancipated minor
Rationale: The correct answer is a 14-year-old girl needing an appendectomy who is not an emancipated minor. Informed consent can be given by individuals who are competent and not minors. Minors are generally unable to provide informed consent unless they are emancipated. Choice A is incorrect because an 86-year-old male with advanced Alzheimer’s disease is considered incompetent to make decisions. Choice D is incorrect because a 6-month-old baby is unable to provide consent. Emancipated minors are an exception to the minor rule, as they can provide consent for their own treatment.
2. Quality is defined as a combination of all of the following except:
- A. conforming to standards.
- B. performing at the minimally acceptable level.
- C. meeting or exceeding customer requirements.
- D. exceeding customer expectations.
Correct answer: performing at the minimally acceptable level.
Rationale: The correct answer is 'performing at the minimally acceptable level.' Quality is about meeting or exceeding customer requirements and expectations, as well as conforming to standards. The term 'performing at the minimally acceptable level' implies just meeting the minimum requirements, which falls short of the comprehensive definition of quality in terms of customer satisfaction and excellence. Therefore, this choice is the exception when defining quality. Choices A, C, and D align with the definition of quality as they all involve meeting or surpassing certain criteria for customer satisfaction and product excellence, which are essential components of quality management.
3. A client with urinary tract calculi needs to avoid which of the following foods?
- A. lettuce
- B. cheese
- C. apples
- D. broccoli
Correct answer: cheese
Rationale: A client with urinary tract calculi needs to avoid foods high in calcium to prevent the formation of more stones. Cheese is high in calcium, so it should be avoided. Lettuce, apples, and broccoli are not typically associated with high calcium content and are safe options for individuals with urinary tract calculi. Therefore, the correct answer is cheese. Choices A, C, and D are not high in calcium and are safe for consumption by individuals with urinary tract calculi.
4. A small amount of bubbling is seen in the water seal of a pleural drainage system when a client coughs. What should the nurse do?
- A. Consider it a normal finding.
- B. Check the system for leaks.
- C. Clamp the chest tube.
- D. Change the drainage system.
Correct answer: Consider it a normal finding.
Rationale: A small amount of bubbling is a normal finding in the water seal of a pleural drainage system when a client coughs. It is only a problem to find continuous, excessive bubbling in the water seal, which indicates a leak. Checking the system for leaks would be appropriate if there is continuous, excessive bubbling. Clamping the chest tube or changing the drainage system is not necessary in response to a small amount of bubbling during a cough, as this is considered a normal finding.
5. A woman who delivered a healthy newborn 6 hours earlier complains of discomfort at the episiotomy site. Which action by the nurse is the most appropriate?
- A. Administering an intravenous (IV) opioid analgesic
- B. Assisting the woman in taking a warm sitz bath
- C. Applying an ice pack to the perineum
- D. Contacting the registered nurse
Correct answer: Applying an ice pack to the perineum
Rationale: Applying an ice pack to the perineum is the most appropriate action in this scenario. Ice causes vasoconstriction, providing relief by numbing the area and preventing edema. It is typically used within the first 12 to 24 hours after birth. Assisting the woman in taking a warm sitz bath is more suitable after 24 hours as warm water can be soothing. Administering an IV opioid analgesic is excessive; an anesthetic spray is more appropriate for surface discomfort. Contacting the registered nurse is unnecessary as applying an ice pack is within the nurse's scope and can effectively address the discomfort without escalation.
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