NCLEX-PN
NCLEX PN Test Bank
1. A client has signed the informed consent for mastectomy of the left breast. On the morning of the surgical procedure, the client asks the nurse several questions about the procedure that make it obvious that she does not have an adequate comprehension of the procedure. What is the most appropriate response by the nurse?
- A. Telling the client that she needed to ask these questions before signing the informed consent for surgery
- B. Contacting the surgeon and requesting that she visit the client to answer her questions
- C. Informing the client that she has the right to cancel the surgical procedure if she wishes
- D. Telling the client that it is her surgeon's responsibility to explain the procedure
Correct answer: B
Rationale: Informed consent is the authorization by a client or a client's legal representative to do something to the client. The surgeon is primarily responsible for explaining the surgical procedure and obtaining informed consent. If the client asks questions that alert the nurse to an inadequacy of comprehension on the client's part, the nurse has the obligation to contact the surgeon. Choice A is incorrect as the client should be allowed to ask questions even after signing the consent for surgery. Choice C is not the most appropriate response, as the primary concern is to address the client's lack of comprehension. Choice D is inaccurate, as while it is the surgeon's responsibility to explain the procedure, in this scenario, the nurse should take immediate action to ensure the client's understanding. Requesting the surgeon to visit and answer the client's questions is the most appropriate response in this situation, as it directly addresses the client's concerns and ensures proper informed consent is obtained.
2. What spinal change occurring with pregnancy alters mobility?
- A. Scoliosis.
- B. Kyphosis.
- C. Lordosis.
- D. Ankylosing spondylitis.
Correct answer: C
Rationale: The correct answer is 'Lordosis.' During pregnancy, the enlarging uterus places increased weight on the spine, causing an exaggerated inward curvature known as lordosis. This change alters mobility by shifting the center of gravity forward, leading to a compensatory change in posture. Scoliosis (choice A) is a sideways curvature of the spine, not typically associated with pregnancy. Kyphosis (choice B) is an exaggerated outward curvature of the spine, while ankylosing spondylitis (choice D) is a chronic inflammatory condition affecting the spine, neither of which are directly related to the spinal changes seen in pregnancy.
3. The nurse receives an assignment of three clients. Which of the following should the nurse consider as the highest priority when determining which client to assess first?
- A. the client who most recently rang their call bell
- B. the client who has been waiting the longest for their call bell to be answered
- C. the client who is in the most pain
- D. the client who may have a risk for an airway obstruction
Correct answer: D
Rationale: The nurse should prioritize assessing a client with a potential airway obstruction first based on the ABCs (airway, breathing, circulation) principle. Maintaining a clear airway is crucial for oxygenation and ventilation, making it the highest priority. Choices A and B focus on call bells and waiting times, which are important but not life-threatening in comparison to airway concerns. While pain management is essential, it takes precedence after addressing immediate life-threatening issues like airway compromise.
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 the following nursing diagnoses might be appropriate as Parkinson's disease progresses and complications develop?
- A. Impaired Physical Mobility
- B. Dysreflexia
- C. Hypothermia
- D. Impaired Dentition
Correct answer: A
Rationale: As Parkinson's disease progresses and complications develop, impaired physical mobility is a relevant nursing diagnosis due to symptoms like a shuffling gait and rigidity that can impair movement. Dysreflexia is not typically associated with Parkinson's disease; it is more commonly seen in spinal cord injuries. Hypothermia is a condition of low body temperature and is not directly related to Parkinson's disease progression. Impaired Dentition involves issues with teeth and oral health, which are not specific to Parkinson's disease complications.
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