NCLEX NCLEX-PN
Nclex PN Questions and Answers
1. A nurse calls a health care provider to question a prescription written for a higher-than-normal dosage of morphine sulfate. The health care provider changes the prescription to a dosage within the normal range, and the nurse documents the new telephone prescription in accordance with the agency’s guidelines in the client’s record. Which other statement does the nurse document in the nursing notes?
- A. The health care provider made a mistake in the written prescription for morphine sulfate.
- B. An inaccurate dosage of morphine sulfate was prescribed and the health care provider was informed.
- C. The health care provider was contacted to correct a mistake in the dosage of morphine sulfate.
- D. The health care provider was contacted to clarify the prescription for morphine sulfate
Correct answer: The health care provider was contacted to clarify the prescription for morphine sulfate
Rationale: The nurse needs to document a factual, descriptive, and objective statement that does not include words indicating that an individual made a mistake or performed an incorrect action or procedure. If a health care provider’s prescription must be questioned, the nurse should record that clarification regarding the prescription was sought. Therefore, the correct statement to document is that the health care provider was contacted to clarify the prescription for morphine sulfate. Choices A, B, and C imply errors or mistakes on the part of the health care provider, which is not the focus of the documentation in this scenario.
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 delivered a term male infant four hours ago. The infant was stillborn. Which room assignment would be most appropriate for this client?
- A. Request a private room on the GYN floor
- B. Assign her to a private room on the postpartum unit
- C. Discharge her home as soon as her condition is stable
- D. Room her with another client who experienced a pregnancy loss
Correct answer: Request a private room on the GYN floor
Rationale: In this situation, the most appropriate room assignment for the client who delivered a stillborn infant would be to request a private room on the GYN floor. This client needs privacy to grieve, and having a private space allows for family members to offer support. Placing her in a GYN unit ensures that she is away from the maternity unit's sights and sounds, which could be painful reminders for her. Assigning her to a postpartum unit may cause distress due to the presence of other mothers and newborns. Discharging her home too early may not allow her sufficient time for emotional and physical recovery. Rooming her with another client who experienced a pregnancy loss may not provide the necessary privacy and space she needs for her emotional well-being.
4. All of the following interventions should be performed when fetal heart monitoring indicates fetal distress except:
- A. Increase maternal fluids.
- B. Administer oxygen.
- C. Decrease maternal fluids.
- D. Turn the mother.
Correct answer: Decrease maternal fluids.
Rationale: When fetal heart monitoring indicates fetal distress, interventions are aimed at improving oxygenation to the fetus. Increasing maternal fluids helps improve placental perfusion and oxygen delivery to the fetus. Administering oxygen also aids in increasing oxygen supply to the fetus. Turning the mother can help relieve pressure on the vena cava, optimizing blood flow to the placenta. Therefore, decreasing maternal fluids would not be performed as it can further compromise placental perfusion and fetal oxygenation, making it the exception. Decreasing maternal fluids could potentially exacerbate fetal distress by reducing oxygen delivery and nutrient supply to the fetus, which is contrary to the goal of managing fetal distress.
5. When caring for African-American clients, what is an important consideration regarding their needs?
- A. Families may have specific needs.
- B. Special hair, skin, and nail care might be required.
- C. Cultural diets should be respected.
- D. Clients are generally future-oriented.
Correct answer: B
Rationale: Correct answer: Special hair, skin, and nail care might be required. African-American clients may have specific hair, skin, and nail care needs due to their unique characteristics such as curly hair and melanin-rich skin. It is important for healthcare providers to be knowledgeable about these needs to provide appropriate care. Option A is incorrect as it does not address the specific care aspect related to the clients themselves. Option C is incorrect as assuming all African-American clients follow cultural diets is a stereotype and may not apply to every individual. Option D is incorrect as being future-oriented is not a characteristic that is universally applicable to African-American clients and does not directly impact nursing care considerations.
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