NCLEX-PN
NCLEX PN Test Bank
1. While receiving an infusion of cefazolin sodium, the client complained of itchy skin. The nurse observed warm, flushed skin with a red rash on the arms, chest, and back. The health care provider was promptly notified.
- A. The client is apparently allergic to cefazolin sodium, as indicated by warm, flushed skin and a rash on the arms, chest, and back.
- B. The client had an allergy to cefazolin sodium.
- C. The health care provider was notified because a rash developed while the client was receiving cefazolin sodium.
- D. During an infusion of cefazolin sodium, the client complained that his skin was itchy. The client's skin was warm and flushed, with a red rash on the arms, chest, and back. The health care provider was notified.
Correct answer: D
Rationale: Accurate and objective documentation is essential during an incident report. Choice A makes an assumption of allergy based on subjective interpretation, which is not appropriate. Choice B states a conclusion without proper documentation. Choice C is incomplete as it fails to provide a detailed account of the observed symptoms. Choice D offers a precise description of the client's symptoms, actions taken, and notification of the healthcare provider, making it the most suitable documentation choice.
2. What does carrying a donor card for organ donation mean?
- A. medical care is altered to obtain organs for donation in the event of serious injuries
- B. the family or legally responsible party of a client has no decision-making authority in the event that the client is considered for organ donation
- C. a client is allowed to revoke their decision for organ donation at any time
- D. a client is considered an organ donor for multiple organs or tissues
Correct answer: C
Rationale: Carrying a donor card for organ donation signifies that an individual can decide to revoke their decision for organ donation at any point. This choice empowers the individual to change their mind regarding organ donation. The family or legally responsible party of a client still holds decision-making authority in the event that the client is considered for organ donation. When organ donation is being considered, all organs or tissues the donor wishes to donate are evaluated for donation suitability; it's not limited to just one organ or tissue. It's important to note that medical care for an individual is not altered to hasten the declaration of death for organ donation purposes; the focus is on providing immediate care and resuscitation to the individual.
3. The laws enacted by states to provide immunity from liability to persons who provide emergency care at an accident scene are called:
- A. Good Samaritan laws.
- B. HIPAA.
- C. Patient Self-Determination Act (PSDA).
- D. OBRA.
Correct answer: A
Rationale: The correct answer is Good Samaritan laws. These laws protect individuals who provide voluntary emergency care from being held liable for any unintended injury or harm that may occur during the care. Good Samaritan laws encourage individuals to assist in emergencies without fear of legal repercussions. HIPAA, on the other hand, focuses on safeguarding patient information and privacy, ensuring confidentiality. The Patient Self-Determination Act (PSDA) pertains to a patient's rights to make decisions about their medical treatment and advance directives. OBRA, enacted in the late 1980s, aims to improve the quality of care in nursing homes and enhance residents' quality of life, focusing on nursing home reform and standards, which is not directly related to immunity for emergency care providers.
4. A client is refusing to stay in the hospital because he does not agree with his healthcare treatment plan. The nurse stops the client from leaving due to concern for his health. Which of these legal charges could the nurse face?
- A. False imprisonment, as the nurse is not allowing the client to leave as he has decided to.
- B. Malpractice, as the nurse is intentionally keeping the patient from making his own decisions, thus violating that nursing duty.
- C. Invasion of privacy, as the nurse is getting involved in the patient's private decisions regarding healthcare.
- D. Negligence, as the nurse ignored the client's right to choose regarding his healthcare.
Correct answer: A
Rationale: Refusing to let a client leave against medical advice (AMA) is a form of false imprisonment. In this scenario, the nurse is restricting the client's freedom of movement by preventing him from leaving the hospital, even though he has expressed his wish to leave. False imprisonment is a legal charge the nurse could face in this situation. The other options are incorrect: - Malpractice refers to professional negligence or failure to provide adequate care, not allowing a patient to make their own decisions. - Invasion of privacy involves disclosing confidential information without consent, not preventing a patient from leaving. - Negligence is the failure to take reasonable care, but it does not specifically address the act of restricting a patient from leaving against their wishes.
5. When should the biohazard emblem be affixed to containers according to the orientation nurse educator reviewing the biohazard legend with a class of new employees?
- A. when there is presence of blood and body fluids.
- B. when there is the need for droplet precautions.
- C. when there is contact isolation.
- D. when there is the potential for airborne transmission.
Correct answer: A
Rationale: The correct answer is 'when there is presence of blood and body fluids.' When handling body substances like blood and body fluids, the risk of transmission of infections increases. Federal regulations mandate warning labels on containers to alert employees and waste collectors. The biohazard emblem consists of a three-ring symbol overlaying a central concentric ring. Blood, wound drainage, feces, and urine are examples of body fluids that can transmit infections and diseases to others. The other choices, B, C, and D, are incorrect because the presence of the biohazard emblem is specifically linked to the handling of blood and body fluids, not to droplet precautions, contact isolation, or airborne transmission.
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