NCLEX NCLEX-PN
NCLEX PN Test Bank
1. A nurse planning care for her assigned clients understands that which aspect is the purpose of the hospital’s standards of care?
- A. Identify methods of treatment.
- B. Provide direction for care based on the client’s diagnosis.
- C. Identify new care methods based on current medical research.
- D. Provide direction for the practice of nursing
Correct answer: Provide direction for the practice of nursing
Rationale: The purpose of the hospital’s standards of care is to provide a broad direction for the overall practice of nursing that applies to all nursing situations, across specialty areas, and across the country. These standards guide the practice of nursing by outlining the expected level of care and professional performance. While identifying methods of treatment is important, it is usually specific to individual client needs and not the overarching goal of standards of care. Providing direction for care solely based on the client’s diagnosis is limited to a particular patient's treatment plan and does not encompass the broader scope of nursing practice. Identifying new care methods based on current medical research is essential for advancing healthcare practices but is not the primary purpose of the hospital’s standards of care.
2. What is the therapeutic range for carbamazepine (Tegretol)?
- A. 7-12 mcg/mL
- B. 4-10 mcg/mL
- C. 10-14 mcg/mL
- D. 1-5 mcg/mL
Correct answer: 4-10 mcg/mL
Rationale: The therapeutic range for carbamazepine (Tegretol) is 4-10 mcg/mL. This range is established based on the optimal balance between effectiveness and safety. Choices A, C, and D are outside the therapeutic range for carbamazepine, which could lead to suboptimal treatment outcomes or increased risk of toxicity. Choice B (4-10 mcg/mL) is the correct range recommended for therapeutic efficacy while minimizing adverse effects.
3. A nurse preparing to examine a client’s eyes plans to perform a confrontation test. The nurse tells the client that this test measures which aspect of vision?
- A. Near vision
- B. Color vision
- C. Distant vision
- D. Peripheral vision
Correct answer: D
Rationale: The correct answer is D: Peripheral vision. The confrontation test is a gross measure of peripheral vision. It compares the client’s peripheral vision with the nurse’s, assuming that the nurse’s vision is normal. During the test, the nurse positions themselves at eye level with the client, about 2 feet away, and directs the client to cover one eye with an opaque card. The nurse covers the eye opposite the client’s covered one and slowly moves a target (like a pencil) from the periphery in several directions. The client is asked to indicate when they see the target, which should coincide with when the nurse sees it. Near vision is tested using a handheld vision screener with various sizes of print, color vision with the Ishihara test, and distant vision with a Snellen chart. Therefore, choices A, B, and C are incorrect as they do not measure peripheral vision, which is the focus of the confrontation test.
4. A client has a 10% dextrose in water IV solution running. He is scheduled to receive his antiepileptic drug, phenytoin (Dilantin), at this time. The nurse knows that the phenytoin:
- A. is given after the D10W is finished.
- B. should be given at the time it is due in the medication port closest to the client.
- C. can be piggybacked into the D10W solution now.
- D. is incompatible with dextrose solutions.
Correct answer: is incompatible with dextrose solutions.
Rationale: Phenytoin is incompatible with dextrose solutions as they will precipitate when mixed together. Therefore, it should not be piggybacked into the D10W solution or given through the same port. Instead, normal saline should be used to flush before and after administering phenytoin to prevent any interaction with the dextrose solution. Delaying the administration of an antiepileptic drug like phenytoin to maintain therapeutic blood levels is not recommended, so it should not be given after the D10W is finished or based on the medication port closest to the client. Choice A is incorrect because administering phenytoin after the D10W is finished is not the correct approach due to the incompatibility with dextrose solutions. Choice B is incorrect as the timing of phenytoin administration should not be based on the medication port closest to the client but on compatibility considerations. Choice C is incorrect as piggybacking phenytoin into the D10W solution is not advisable due to the incompatibility issue.
5. After undergoing gastric resection, the client is informed by the nurse that which of the following meals is most likely to cause rapid emptying of the stomach?
- A. a high-protein meal
- B. a high-fat meal
- C. a large meal regardless of nutrient content
- D. a high-carbohydrate meal
Correct answer: a high-carbohydrate meal
Rationale: After gastric resection, meals high in carbohydrates are more likely to cause rapid emptying of the stomach. Carbohydrates stimulate the release of gastrin, which accelerates gastric emptying. On the other hand, high-fat and high-protein meals tend to delay gastric emptying. A large meal, regardless of nutrient content, can also delay gastric emptying due to the increased volume of food that needs to be processed.
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