NCLEX-PN
Nclex PN Questions and Answers
1. During a hospital program about in vitro fertilization, a television crew arrives to film for a series on hospital services. What action should the nurse conducting the program take?
- A. Ask the television crew to interview the individuals attending the program individually.
- B. Allow the television crew to videotape the program as long as they do not publicize that the program is about in vitro fertilization.
- C. Explain to the television crew that videotaping is not allowed.
- D. Allow the television crew to videotape the program.
Correct answer: C
Rationale: Privacy is a client's right to be free from unwanted intrusion into their private affairs. Videotaping constitutes an invasion of a client's privacy, and written permission is required from the client for actions such as photographing or videotaping. Therefore, the nurse must explain to the television crew that videotaping is not allowed to protect the attendees' privacy. Option A is incorrect as it still involves recording the individuals, breaching their privacy. Option B is incorrect because allowing videotaping without consent violates privacy rights. Option D is incorrect as it disregards the need for consent and privacy protection.
2. Which is an appropriate outcome for the nursing diagnosis of Body Image Disturbance for a client with anorexia nervosa?
- A. The client verbalizes knowledge of a maintenance diet.
- B. The client demonstrates assertiveness with family.
- C. The client verbalizes her body size accurately.
- D. The client demonstrates control of obsessive behaviors.
Correct answer: C
Rationale: The correct answer is 'The client verbalizes her body size accurately.' For clients with anorexia nervosa, body image disturbance is a common issue where they perceive themselves inaccurately. Verbalizing her body size accurately indicates progress towards correcting this distorted self-perception. Choices A, B, and D are incorrect because they do not directly address the distorted body image perception seen in clients with anorexia nervosa. Choice A focuses on knowledge of a maintenance diet, which is unrelated to body image perception. Choice B involves assertiveness with family, which is more related to family dynamics. Choice D addresses control of obsessive behaviors, which is not directly related to correcting the distorted body image perception.
3. Which of the following foods present a problem for a client diagnosed with Celiac Disease?
- A. butter
- B. oats or barley cereal
- C. fresh vegetables
- D. coffee or tea
Correct answer: B
Rationale: Celiac disease, also known as celiac sprue, is a malabsorption disorder affecting the small intestine due to a problem with ingesting gluten, a protein found in wheat, rye, oats, and barley. Therefore, oats or barley cereal would present a problem for a client with Celiac Disease as they contain gluten. Fresh vegetables, butter, coffee, and tea, on the other hand, do not contain gluten and should not pose any issues for individuals with this disorder. Therefore, the correct answer is oats or barley cereal. Choices A, C, and D are not problematic for clients with Celiac Disease as they are gluten-free.
4. The ICU nurse caring for a client who has just been declared brain dead can expect to find evidence of the client's wishes regarding organ donation:
- A. on the client's driver's license.
- B. in the client's safety deposit box.
- C. in the client's last will and testament.
- D. on the client's insurance card.
Correct answer: A
Rationale: In most states, indication of organ donor status is found on the client's driver's license, making it easily accessible for decision-making in critical situations like declaring brain death. Evidence in a last will and testament or a safety deposit box may not be promptly available. Information about organ donation is typically not included on insurance cards. The primary care physician's health record documentation could also be a relevant source for the ICU nurse. Therefore, the correct answer is finding evidence of the client's wishes regarding organ donation on the client's driver's license.
5. To remove hard contact lenses from an unresponsive client, what should the nurse do?
- A. Gently irrigate the eye with an irrigating solution from the inner canthus outward
- B. Grasp the lens with a gentle pinching motion
- C. Don sterile gloves before attempting the procedure
- D. Ensure that the lens is centered on the cornea before gently manipulating the lids to release the lens
Correct answer: D
Rationale: When removing hard contact lenses from an unresponsive client, the nurse should ensure that the lens is centered on the cornea before gently manipulating the lids to release the lens. This approach helps prevent scratching the cornea. Gently maneuvering the upper and lower eyelids assists in loosening the lens for easy removal. Options A, B, and C are incorrect because irrigating the eye, grasping the lens, or wearing sterile gloves are not recommended methods for removing hard contact lenses. It is crucial to handle the situation delicately to avoid causing harm or discomfort to the client.
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