NCLEX 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: Explain to the television crew that videotaping is not allowed.
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. A 6-month-old client is admitted with possible intussusception. Which question during the nursing history is least helpful in obtaining information regarding this diagnosis?
- A. “Tell me about his pain.”
- B. “What does his vomit look like?”
- C. “Describe his usual diet.”
- D. “Have you noticed changes in his abdominal size?”
Correct answer: “Describe his usual diet.”
Rationale: The least helpful question in obtaining information regarding intussusception is “Describe his usual diet.” This question is least relevant to the specific symptoms and presentation of intussusception. Choices A, B, and D are more directly related to symptoms commonly associated with intussusception and can provide important diagnostic clues. Asking about pain, vomit appearance, and changes in abdominal size can help in assessing the severity and progression of the condition, making them more crucial questions to ask in this scenario. Pain is a cardinal symptom of intussusception, changes in vomit appearance may indicate gastrointestinal issues, and alterations in abdominal size can signify the presence of a mass or obstruction, all of which are pertinent in diagnosing and managing intussusception.
3. 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: Contacting the surgeon and requesting that she visit the client to answer her questions
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.
4. After undergoing gastric resection, the client is informed by the nurse that which of the following meals is most likely to cause rapid emptying of the stomach?
- A. a high-protein meal
- B. a high-fat meal
- C. a large meal regardless of nutrient content
- D. a high-carbohydrate meal
Correct answer: a high-carbohydrate meal
Rationale: After gastric resection, meals high in carbohydrates are more likely to cause rapid emptying of the stomach. Carbohydrates stimulate the release of gastrin, which accelerates gastric emptying. On the other hand, high-fat and high-protein meals tend to delay gastric emptying. A large meal, regardless of nutrient content, can also delay gastric emptying due to the increased volume of food that needs to be processed.
5. When planning task assignments for five clients on the skilled nursing unit in a long-term care facility, which task should a licensed practical nurse (LPN) assign to another LPN?
- A. Bathing a client who is confused and requires assistance with a shower
- B. Administering regular insulin in accordance with a sliding-dosage scale every 4 hours to a client with diabetes mellitus
- C. Assisting a client requiring a bed bath and frequent ambulation with a cane
- D. Transporting a client who must be accompanied to physical therapy twice during the shift
Correct answer: Administering regular insulin in accordance with a sliding-dosage scale every 4 hours to a client with diabetes mellitus
Rationale: When assigning tasks, the nurse must consider the skills and educational level of the nursing staff. The nursing assistant may be assigned tasks like caring for a confused client, assisting with a shower or a bed bath, ambulating a client with a cane, and accompanying a client to physical therapy. The LPN is educated to administer medications like regular insulin in accordance with a sliding scale. This task requires a higher level of training and knowledge than the tasks that can be delegated to a nursing assistant. Administering insulin involves assessing blood glucose levels, calculating dosages, and understanding the effects of insulin therapy on the client's condition. Therefore, the correct answer is administering regular insulin to a client with diabetes mellitus. Choices A, C, and D involve tasks that are within the scope of practice of a nursing assistant, not an LPN.
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