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. What should be the primary action for a client who has just vomited 300 cc of bright red blood?
- A. Document the vomiting.
- B. Increase IV fluids.
- C. Get a complete blood count.
- D. Check the blood pressure.
Correct answer: D
Rationale: The correct first action for a client who has just vomited 300 cc of bright red blood is to check the blood pressure. This assessment is crucial to evaluate for hypotension, which could indicate significant blood loss and the need for immediate intervention. Documenting the vomiting is important for the client's medical record but not the initial priority. Increasing IV fluids and getting a complete blood count are necessary steps but should follow the assessment of the client's hemodynamic status.
3. Upon admission, the client expresses a desire for an extra oxygen tank in their room due to a previous breathing issue. What is the most appropriate response?
- A. "I will make sure there is always an extra oxygen tank in your room."?
- B. "I will ask the previous nurse if the extra tank was needed."?
- C. "I will need to check if your insurance benefits would cover an additional oxygen tank."?
- D. "The first priority is ensuring there are enough oxygen tanks for everyone who needs them. I am not sure we will be able to provide an extra on standby."?
Correct answer: D
Rationale: The appropriate response in this situation is to prioritize the availability of oxygen tanks for all patients in need. While it is understandable that the client may desire an extra tank for reassurance, the healthcare facility must ensure equitable distribution based on clinical need. Option A is incorrect because promising an always available extra tank may not be feasible and can set unrealistic expectations. Option B is not the best response as it focuses on past actions rather than addressing the current situation. Option C is not the most appropriate response at this time as the client's immediate need for an extra oxygen tank is the primary concern. Therefore, the best response is to emphasize the importance of equitable distribution of resources while acknowledging the client's request for an extra tank.
4. A nurse working the 7 a.m. to 3 p.m. shift is reviewing the records of the assigned clients. Which client should the nurse assess first?
- A. A client scheduled for hemodialysis at 10 a.m.
- B. A client scheduled for contrast computed tomography (CT) at noon.
- C. A client scheduled for a nuclear scanning procedure at 10 a.m.
- D. A client scheduled for hydrotherapy for the treatment of a burn injury at 10:30 a.m.
Correct answer: A
Rationale: The correct answer is the client scheduled for hemodialysis at 10 a.m. This client needs immediate assessment before the procedure, which may take up to 5 hours. The nurse should ensure the client is physically and emotionally prepared, check for fluid overload by assessing weight and lung sounds, review vital signs, and laboratory test results. The other clients described in the options have needs that are not as urgent. The client scheduled for a nuclear scanning procedure at 10 a.m. may require information reinforcement and increased fluid intake before the procedure. The client scheduled for hydrotherapy for the treatment of a burn injury at 10:30 a.m. may need pain medication administered 30 minutes prior to the therapy. The client scheduled for a contrast CT at noon may need procedure information reinforcement and a special contrast preparation just before the procedure.
5. What type of injury is associated with acute hyphema?
- A. orthopedic
- B. eye
- C. insect sting or snakebite
- D. gynecological trauma
Correct answer: B
Rationale: Acute hyphema is associated with an eye injury, typically resulting from blunt trauma. The presence of blood in the anterior chamber of the eye causes a half-moon appearance or a horizontal line across the globe when the client is upright. Choices A, C, and D are incorrect because acute hyphema is not related to orthopedic injuries, insect stings, snakebites, or gynecological trauma.
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