NCLEX NCLEX-PN
NCLEX PN Test Bank
1. A nurse is planning client assignments for the day. Which task should the nurse assign to the nursing assistant (unlicensed assistive personnel)?
- A. Recording the urinary output for a client with renal calculi whose urine must be strained
- B. Dressing change instructions for a client who had a mastectomy 2 days ago
- C. Reporting abnormal lab values to the health care provider for a client scheduled for a laparoscopic cholecystectomy
- D. Preprocedural teaching for a client scheduled for a cardiac stress test
Correct answer: Recording the urinary output for a client with renal calculi whose urine must be strained
Rationale: The nurse is legally responsible for client assignments and must assign tasks based on state nursing practice act guidelines and job descriptions provided by the employing agency. The nursing assistant is trained to measure, collect, and strain urine, making recording urinary output for a client with renal calculi a suitable task for the nursing assistant. This task falls within the nursing assistant's role description. Dressing change instructions for a client who had a mastectomy involve a higher level of skill and knowledge, beyond the scope of a nursing assistant. Reporting abnormal lab values to the health care provider for a client scheduled for a laparoscopic cholecystectomy requires interpretation and clinical judgment, which is typically not within the nursing assistant's role. Preprocedural teaching for a client scheduled for a cardiac stress test involves providing detailed information and education, which is usually the responsibility of a licensed nurse or other qualified healthcare provider.
2. For a client with suspected appendicitis, in which quadrant should the nurse expect to find abdominal tenderness?
- A. upper right
- B. upper left
- C. lower right
- D. lower left
Correct answer: lower right
Rationale: The correct answer is C: lower right. Abdominal tenderness in the lower-right quadrant is a classic sign of appendicitis. The appendix is located in the lower right abdomen, so inflammation of the appendix typically causes tenderness in this specific area. Choices A, B, and D are incorrect because tenderness in the upper right, upper left, and lower left quadrants, respectively, is not typical in appendicitis cases. Therefore, the nurse should focus on assessing the lower right quadrant for tenderness when suspecting appendicitis.
3. 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.
4. What is the primary theory that explains a family’s concept of health and illness?
- A. Health Belief Model
- B. Education Factor
- C. Family Health Belief Model
- D. Family Dynamics Model
Correct answer: Health Belief Model
Rationale: The correct answer is the Health Belief Model. The Health Belief Model is a widely recognized theory that explains individuals' perceptions and behaviors related to health and illness. It considers factors such as perceived susceptibility, severity of health issues, benefits of action, and barriers to taking action. Choices B, C, and D are incorrect. Choice B, 'Education Factor,' is too general and does not specifically address a family's concept of health and illness. Choice C, 'Family Health Belief Model,' is a combination of terms and not a recognized theory. Choice D, 'Family Dynamics Model,' focuses on family interactions rather than explaining a family's concept of health and illness.
5. When a client informs the nurse that he is experiencing hypoglycemia, the nurse provides immediate intervention by offering:
- A. one commercially prepared glucose tablet.
- B. two hard candies.
- C. 4–6 ounces of fruit juice.
- D. 2–3 teaspoons of honey.
Correct answer: 2–3 teaspoons of honey.
Rationale: The correct answer is 2–3 teaspoons of honey. In the case of hypoglycemia, the usual recommendation for treatment is 10–15 grams of fast-acting simple carbohydrate orally if the client is conscious and able to swallow. This can be achieved by providing 2–3 teaspoons of honey. While commercially prepared glucose tablets or 4–6 ounces of fruit juice are also suitable choices, adding sugar to unsweetened juice is unnecessary as the fruit sugar in juice contains enough simple carbohydrate to raise blood glucose levels. Adding sugar could lead to a sharp and prolonged increase in blood sugar levels. Two hard candies may not provide the recommended 10–15 grams of fast-acting carbohydrate needed for quick elevation of blood glucose levels in cases of hypoglycemia.
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