NCLEX-PN
NCLEX PN Test Bank
1. A nurse is watching as a new nurse employee administers an intramuscular (IM) injection in a client's deltoid muscle. The nurse determines that the new employee is performing the procedure correctly if the new employee uses which technique?
- A. Administers the injection 2 inches below the acromion process
- B. Positions the client with the deltoid muscle exposed
- C. Administers the injection in the thigh
- D. Places the client in the Sims position
Correct answer: A
Rationale: When administering an intramuscular injection in the deltoid muscle, the correct technique involves administering the injection 2 inches below the acromion process, which is the bony structure on top of the shoulder blade. This location ensures safe and effective administration. Administering the injection in the thigh (vastus lateralis or rectus femoris muscle) is not appropriate for a deltoid injection as the deltoid muscle is located in the upper arm. The Sims position is not the correct position for a deltoid muscle injection. While positioning the client with the deltoid muscle exposed allows for proper access and visualization, the critical aspect for a correct deltoid injection is the accurate injection site, 2 inches below the acromion process.
2. During an annual physical exam, a client is diagnosed with Benign Prostatic Hyperplasia (BPH). This client is likely to have a consult with which type of physician?
- A. gynecologist
- B. physiatrist
- C. urologist
- D. proctologist
Correct answer: C
Rationale: A client diagnosed with Benign Prostatic Hyperplasia (BPH) would typically have a consult with a urologist. Urologists specialize in urinary tract and prostatic diseases, making them the appropriate choice for managing BPH. A gynecologist focuses on diseases of the female reproductive tract, so they are not relevant in this case. A physiatrist specializes in rehabilitation care, which is not directly related to the treatment of BPH. A proctologist specializes in lower colonic digestive diseases, which are unrelated to BPH.
3. A health care provider asks the nurse caring for a client with a new colostomy to request the hospital's stoma nurse to visit the client and assist with colostomy care. The nurse initiates the consultation, understanding that the stoma nurse will be able to influence the client because of which type of power?
- A. Expert power
- B. Referent power
- C. Coercive power
- D. Reward power
Correct answer: A
Rationale: Power is the ability to influence others to achieve goals. Expert power results from knowledge and skills that one possesses that are needed by others. In this scenario, the stoma nurse's expertise in colostomy care gives them the ability to influence the client effectively. Reward power is based on the ability to grant rewards and favors, which is not applicable in this situation. Coercive power is based on fear and the ability to punish, which is not the case in seeking assistance for colostomy care. Referent power results from followers' desire to identify with a powerful person, which is not the primary influence in this context.
4. How many temporary teeth should the nurse expect to find in a 5-year-old client's mouth?
- A. up to 10
- B. up to 15
- C. up to 20
- D. up to 32
Correct answer: C
Rationale: A 5-year-old child can have up to 20 temporary (deciduous or baby) teeth. The first tooth usually erupts by age 6 months, and the last by age 30 months. All temporary teeth are usually shed between 6 and 13 years of age. Therefore, a 5-year-old child should have up to 20 temporary teeth. The correct answer is 'up to 20.' Choices A, B, and D are incorrect because the correct number of temporary teeth in a 5-year-old child's mouth is up to 20, not 10, 15, or 32.
5. Which of these clients should the LPN/LVN see first?
- A. a client with a newly placed NG tube who is complaining of pain around the face and a plugged nose
- B. a post-op prostatectomy client who complains of bladder spasms and blood in his foley bag
- C. a client in an arm cast who is 2 days post-op and reports feelings of numbness and tingling in her affected arm
- D. a client newly diagnosed with Hepatitis A who reports stomach pain and itchy skin
Correct answer: C
Rationale: Numbness and tingling hours or days after a cast is applied may indicate compartment syndrome and should be reported to a medical provider right away. This is a potential emergency situation that requires immediate attention to prevent complications. The other options present expected or typical symptoms related to their diagnosis, which do not require immediate intervention. Complaints related to a newly placed NG tube such as pain around the face and a plugged nose may require assessment and intervention but are not as urgent as potential compartment syndrome. Bladder spasms and blood in the foley bag post-prostatectomy are common postoperative issues that can be addressed after the client in the arm cast with potential compartment syndrome is seen. Stomach pain and itchy skin in a client with Hepatitis A are common symptoms of the condition and do not indicate an emergency situation.
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