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: D
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. Why is accurate documentation of assessment findings regarding pressure ulcers crucial?
- A. To comply with legal requirements for documenting lesions.
- B. To meet hospital policies for documenting lesions.
- C. To fulfill physician's documentation requirements for lesions.
- D. Because the nursing assessment of ulcers is a standard of nursing practice.
Correct answer: D
Rationale: Accurate documentation of assessment findings regarding pressure ulcers is crucial because the nursing assessment of ulcers is a standard practice in nursing care. Documenting these findings not only ensures continuity of care but also plays a vital role in preventing further progression of the ulcer. Choices A, B, and C are incorrect because while laws, hospital policies, and physician requirements may influence documentation practices, the primary reason for accurate documentation lies in the standards of nursing practice and the quality of patient care.
3. Which of the following are antiviral drug classes used in the treatment of HIV/AIDS?
- A. Nucleoside reverse transcriptase inhibitors
- B. Protease inhibitors
- C. HIV fusion inhibitors
- D. All of the above
Correct answer: D
Rationale: The correct answer is 'All of the above.' Nucleoside reverse transcriptase inhibitors inhibit the enzyme reverse transcriptase, protease inhibitors block the activity of the HIV-1 protease enzyme, and HIV fusion inhibitors prevent HIV from entering human cells. Therefore, all the choices provided are valid antiviral drug classes for managing HIV/AIDS. Nucleoside reverse transcriptase inhibitors, protease inhibitors, and HIV fusion inhibitors play crucial roles in combating the virus at different stages. Nucleoside reverse transcriptase inhibitors target an early stage, protease inhibitors act on a later stage, and HIV fusion inhibitors prevent viral entry. Thus, 'All of the above' is the correct and comprehensive answer encompassing different mechanisms of action in managing HIV/AIDS.
4. A client is refusing to stay in the hospital because he does not agree with his healthcare treatment plan. The nurse stops the client from leaving due to concern for his health. Which of these legal charges could the nurse face?
- A. False imprisonment, as the nurse is not allowing the client to leave as he has decided to.
- B. Malpractice, as the nurse is intentionally keeping the patient from making his own decisions, thus violating that nursing duty.
- C. Invasion of privacy, as the nurse is getting involved in the patient's private decisions regarding healthcare.
- D. Negligence, as the nurse ignored the client's right to choose regarding his healthcare.
Correct answer: A
Rationale: Refusing to let a client leave against medical advice (AMA) is a form of false imprisonment. In this scenario, the nurse is restricting the client's freedom of movement by preventing him from leaving the hospital, even though he has expressed his wish to leave. False imprisonment is a legal charge the nurse could face in this situation. The other options are incorrect: - Malpractice refers to professional negligence or failure to provide adequate care, not allowing a patient to make their own decisions. - Invasion of privacy involves disclosing confidential information without consent, not preventing a patient from leaving. - Negligence is the failure to take reasonable care, but it does not specifically address the act of restricting a patient from leaving against their wishes.
5. A client is complaining of difficulty walking secondary to a mass in the foot. The nurse should document this finding as:
- A. Plantar fasciitis.
- B. Hallux valgus.
- C. Hammertoe.
- D. Morton's neuroma.
Correct answer: D
Rationale: The correct answer is Morton's neuroma. Morton's neuroma is a small mass or tumor in a digital nerve of the foot, causing symptoms such as pain and difficulty walking. Hallux valgus is commonly known as a bunion and involves the deviation of the big toe towards the other toes. Hammertoe is a condition where one or more toes are bent in a claw-like position. Plantar fasciitis is characterized by pain and inflammation in the arch of the foot, not typically associated with a mass causing difficulty walking.
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