NCLEX-PN
Nclex PN Questions and Answers
1. A client is having an abortion in a women's clinic, and the nurse caring for the client does not think the reasoning is appropriate. The nurse asks, "Are you sure you want to do this? It can't be undone. Have you read about your other options? Adoption is always a good choice."? The client states she understands all options and is comfortable with her choice. The nurse nods and leaves the room to discuss the procedure with the physician. Which client right did the nurse violate with her actions?
- A. the client's right to make personal health decisions without interference, as the nurse tried to sway the client's decision-making and healthcare choice in the direction of not having an abortion
- B. the client's right to be left alone without unsolicited attention, as the nurse inserted herself in the client's healthcare scenario and offered uninvited advice
- C. the client's right to confidentiality, as the nurse is talking to the physician about the client and the abortion
- D. the client's right to respectful care, as the nurse clearly made it known that she did not approve of the abortion
Correct answer: A
Rationale: A client has the right to make decisions about their healthcare without interference from healthcare team members. In this scenario, the nurse violated the client's right to make personal health decisions without interference by trying to influence the client's decision-making and healthcare choice in the direction of not having an abortion. It is essential for healthcare providers to respect patients' autonomy and decisions, regardless of personal beliefs. Choices B, C, and D are incorrect because the primary violation in this situation is related to the client's right to make their own healthcare decisions without interference.
2. An Asian family has an elderly member with the latest stage of Alzheimer's disease. The physician has recommended placement in a long-term care facility, but the family refuses. Which of the following is an appropriate response by the nurse?
- A. "You really need to listen to what the physician says."?
- B. "You will get too tired to take care of him at home."?
- C. "What can I do to assist you to care for him at home?"?
- D. "You are too busy to be taking care of an elderly person."?
Correct answer: C
Rationale: The correct answer is, "What can I do to assist you to care for him at home?"? This response shows cultural sensitivity and respect for the family's values. In many Asian cultures, there is a strong tradition of caring for elders at home rather than in a long-term care facility. By offering assistance to the family in caring for their elderly member at home, the nurse shows understanding and support. Choices A, B, and D are incorrect because they do not acknowledge or respect the family's cultural beliefs and values regarding caring for elderly family members.
3. Why is padding on a restraint helpful?
- A. To distribute pressure so that bony prominences do not receive pressure when a client pulls against the restraints.
- B. To help the client feel more secure.
- C. To keep infection and wounds at bay.
- D. To keep restraints in place.
Correct answer: A
Rationale: Padding on a restraint helps distribute pressure to prevent bony prominences from bearing excessive pressure when a client pulls against the restraints. This is crucial to avoid tissue damage caused by ischemia. The correct answer focuses on the physiological benefit of padding in reducing pressure on vulnerable areas to prevent harm. Choice B is incorrect as the primary purpose of padding is not emotional comfort but preventing physical harm. Choice C is incorrect as while padding can indirectly help prevent infection and wounds by reducing pressure, its primary function is pressure distribution. Choice D is incorrect as the main purpose of padding is not to keep the restraints in place but to protect the client's skin and tissues from pressure-related injuries.
4. When documenting in the client’s record, what type of information should be recorded?
- A. educated predictions of outcomes
- B. personal opinions
- C. objective information
- D. subjective information
Correct answer: C
Rationale: When documenting in a client's record, it is crucial to record objective information. Objective information is factual, based on observations and measurable data. This type of information is essential for accurate and effective communication among healthcare professionals involved in the client's care. Choices A and B, educated predictions of outcomes and personal opinions, are subjective in nature and may not provide an accurate representation of the client's condition. Choice D, subjective information, includes personal feelings, interpretations, and opinions, which are not ideal for documentation as they can be biased and unreliable.
5. What is the role of an incident report in risk management?
- A. To provide liability protection.
- B. To provide data for analysis by a risk manager to determine how future problems can be avoided.
- C. To discipline staff for errors.
- D. All of the above.
Correct answer: B
Rationale: The correct answer is B. Incident reports play a crucial role in risk management by providing data for analysis to prevent future problems. They are not primarily for liability protection (A) or disciplining staff (C). Therefore, choice B is the most appropriate answer. Choosing option D is incorrect because incident reports do not solely exist for all the mentioned purposes, but primarily to provide data for analysis and preventive actions.
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