NCLEX-PN
NCLEX PN Test Bank
1. A nursing assistant who has been employed in the long-term care center for 8 weeks is consistently taking extended lunch breaks. The nursing assistant's behavior has caused problems with client care during lunch hours. What is the appropriate way for the nurse to deal with this situation?
- A. Ignoring the situation
- B. Documenting the problem in the nursing assistant's personnel file
- C. Asking other staff members to cover for the nursing assistant
- D. Meeting with the nursing assistant to discuss the behavior and initiate problem-solving measures
Correct answer: D
Rationale: Taking extended lunch breaks is an unacceptable behavior, especially when it affects client care. The appropriate way for the nurse to deal with this situation is to meet with the nursing assistant to discuss the behavior and initiate problem-solving measures. This direct approach allows for open communication and the opportunity to address the issue effectively. Ignoring the situation (Choice A), asking other staff members to cover (Choice C), or documenting the problem in the nursing assistant's personnel file (Choice B) are not effective solutions. Ignoring the behavior does not address the issue, asking others to cover may not solve the problem at its root, and documenting the problem should come after attempting to resolve the issue through communication and problem-solving first.
2. In a centralized decision-making process within an organization, where is the authority to make decisions vested?
- A. Every employee
- B. A few individuals, such as the board of directors
- C. Many individuals, with decisions filtering down to the individual employee
- D. All nursing employees, pharmacists, and hospital health care providers
Correct answer: B
Rationale: In a centralized decision-making process within an organization, the authority to make decisions is concentrated in a few individuals, such as the board of directors. This means that key decision-making power is held by a select group at the top of the organizational hierarchy. Choices A, C, and D are incorrect because in a centralized structure, decision-making authority is not distributed among every employee, does not filter down to individual employees, and is not shared among all nursing employees, pharmacists, or hospital health care providers. Centralized decision-making implies a more top-down approach.
3. When caring for clients with Buck’s Traction, the major areas of importance should be:
- A. nutrition, elimination, comfort, safety
- B. ROM exercises, transportation
- C. nutrition, elimination, comfort, safety
- D. elimination, safety, isotonic exercises
Correct answer: C
Rationale: When caring for clients with Buck’s Traction, the major areas of importance should be nutrition, elimination, comfort, and safety. Proper nutrition, including a diet high in protein with adequate fluids, is essential for healing and recovery. Elimination refers to maintaining regular bowel and bladder function. Comfort is crucial to ensure the patient's well-being while in traction, and safety measures should be followed to prevent complications. Choices A, B, and D are incorrect. ROM exercises are not typically a primary concern with Buck’s Traction, making choices A and B incorrect. Isotonic exercises are not specifically related to the care of a client in Buck's Traction, making choice D incorrect.
4. A licensed practical nurse (LPN) in the long-term care unit who has another LPN and a nursing assistant on the nursing team is planning task assignments for the day. Which task should the nurse assign to the LPN?
- A. Monitoring a client receiving oxygen who requires frequent pulse oximetry monitoring and respiratory treatments
- B. Assisting a client who is wearing eye patches and requires assistance with hygiene measures
- C. Feeding a client on bedrest who needs assistance with feeding
- D. Turning a client who must be turned and repositioned every 2 hours
Correct answer: A
Rationale: When a nurse assigns tasks for a client's care to another staff member, the nurse is responsible for appropriately assigning tasks based on the educational level and competency of the staff member. In this scenario, the LPN should be assigned the task of monitoring a client receiving oxygen who requires frequent pulse oximetry monitoring and respiratory treatments. This is because the LPN is competent to perform these tasks and can accurately note changes in the client's condition. Tasks such as feeding a client, turning and repositioning a client, and assisting with hygiene measures, which are noninvasive interventions, can be assigned to a nursing assistant. These tasks do not require the same level of assessment and monitoring as the respiratory treatments and pulse oximetry monitoring.
5. Which statement about clinical pathways is inaccurate?
- A. They require daily updates.
- B. They illustrate the expected client response to their diagnosis.
- C. The objective is improvement or discharge from the facility.
- D. They are evidence-based.
Correct answer: A
Rationale: The correct answer is that clinical pathways do not necessarily require daily updates. Clinical pathways can be customized to be updated daily, weekly, or at other intervals based on patient needs and facility protocols. Choice A is inaccurate as daily updates are not always mandatory for clinical pathways. Choices B, C, and D are accurate features of clinical pathways: they depict the expected client response to the diagnosis, aim for improvement or discharge, and are grounded in evidence-based practices to ensure optimal care.
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