NCLEX NCLEX-PN
NCLEX PN Test Bank
1. A nurse discusses staff empowerment with the nursing team. The nurse explains that staff empowerment has which function?
- A. Fosters the growth of others so that they are less dependent on the leader
- B. Means that the staff has the power to reprimand and punish any individual who is not meeting the standards of care delivery
- C. Indicates that the nurse leader will make decisions regarding the nursing unit and expects that the staff will comply with the changes
- D. Allows the staff to make every decision regarding employee scheduling
Correct answer: Fosters the growth of others so that they are less dependent on the leader
Rationale: Staff empowerment fosters the growth of others and facilitates their development so that they are less dependent on their leader. This empowerment is about enhancing skills and autonomy, not about reprimanding or punishing others (Choice B). Empowerment involves shared decision-making and autonomy, not unilateral decision-making by the leader (Choice C). Moreover, staff empowerment does not mean that staff should make every decision regarding operational aspects like employee scheduling (Choice D). It is primarily focused on developing individuals' capabilities and fostering independence within the team.
2. What do the following ABG values indicate: pH 7.38, PO2 78 mmHg, PCO2 36 mmHg, and HCO3 24 mEq/L?
- A. metabolic alkalosis
- B. homeostasis
- C. respiratory acidosis
- D. respiratory alkalosis
Correct answer: homeostasis
Rationale: The correct answer is 'homeostasis.' These ABG values fall within the normal range, indicating a state of balance and homeostasis. The pH is within the normal range (7.35-7.45), the PCO2 is normal (35-45 mmHg), and the HCO3 level is also normal (22-26 mEq/L). Choice A, 'metabolic alkalosis,' is incorrect because the pH, PCO2, and HCO3 levels are not indicative of metabolic alkalosis. Choice C, 'respiratory acidosis,' is incorrect as the pH and PCO2 values are not elevated. Choice D, 'respiratory alkalosis,' is incorrect as the pH and PCO2 levels are not decreased. Therefore, the ABG values provided do not correspond to any acid-base disturbance, confirming that the patient is in a state of homeostasis.
3. The doctor orders 2% nitroglycerin ointment in a 1-inch dose every 12 hours. Proper application of nitroglycerin ointment includes:
- A. Rotating application sites
- B. Limiting applications to the chest
- C. Rubbing it into the skin
- D. Covering it with a thin paper dressing
Correct answer: Rotating application sites
Rationale: Proper application of nitroglycerin ointment involves rotating application sites to prevent skin irritation. It should be applied to the back and upper arms, not restricted to the chest, making option B incorrect. Rubbing it into the skin, as indicated in option C, is not recommended for nitroglycerin ointment as it can lead to faster absorption and potential side effects. The correct way is to cover it with a thin paper dressing, not gauze as mentioned in option D, to ensure proper absorption and prevent the medication from evaporating too quickly.
4. A nurse is instructing a patient on the order of sensations with the application of an ice water bath for a swollen right ankle. Which of the following is the correct order of sensations experienced with an ice water bath?
- A. cold, burning, aching, and numbness
- B. burning, aching, cold, and numbness
- C. aching, cold, burning, and numbness
- D. cold, aching, burning, and numbness
Correct answer: A
Rationale: The correct order of sensations experienced with an ice water bath is cold, burning, aching, and numbness, as stated by the acronym CBAN (cold, burn, ache, numbness). Option A is the correct sequence. Choice B is incorrect as it starts with burning, which typically follows the cold sensation. Choice C is incorrect as aching is usually felt after the burning sensation. Choice D is incorrect as aching usually occurs after the burning sensation.
5. A client is taking phenelzine (Nardil), and their spouse would like to bring lunch from home. Which of the following is most appropriate for the client to eat?
- A. a banana
- B. grapefruit
- C. a salami sandwich
- D. avocado slices
Correct answer: grapefruit
Rationale: The correct answer is grapefruit. Clients taking MAO Inhibitors like phenelzine (Nardil) should avoid foods rich in tyramine to prevent hypertensive crisis. Grapefruit is a suitable choice as it is not high in tyramine. Bananas, avocados, and salami are foods that should be avoided due to their tyramine content, which can interact adversely with MAO Inhibitors. Therefore, choosing grapefruit is the safest option for the client.
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