a nursing student is assigned to care for a client who requires a total bed bath when the student explains to the client that she is going to gather s
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Nursing Elites

NCLEX-PN

Nclex PN Questions and Answers

1. A nursing student is assigned to care for a client who requires a total bed bath. When the student explains to the client that she is going to gather supplies to administer the bath, the client states, 'I don't want a bath. I've been up all night, and I'm clean enough.' The student reports the client's refusal to the nurse. Which action by the nurse is appropriate?

Correct answer: B

Rationale: The client has the right to refuse a treatment or procedure, and if the client does refuse, the nurse must respect the client's decision. Therefore, the nurse would allow the client to rest. Persuading the client to have a bath and giving the bath anyway are both inappropriate as they violate the client's rights. Informing the health care provider of the refusal of care can be discussed with the client if needed, but the immediate action should be to respect the client's wishes and allow them to rest.

2. Signs of internal bleeding include all of the following except:

Correct answer: C

Rationale: Vomiting bile is not typically a sign of internal bleeding but is more commonly associated with issues in the gastrointestinal tract. Signs of internal bleeding include painful or swollen extremities, a tender, rigid abdomen, and bruising. Painful or swollen extremities can indicate bleeding from an extremity injury, a tender, rigid abdomen can signal abdominal bleeding, and bruising can result from blood vessel damage. Therefore, the correct answer is 'C: vomiting bile,' as it is not a typical sign of internal bleeding.

3. A nurse is supervising a new nursing graduate in various procedures. Which action by the new nursing graduate constitutes a negligent act?

Correct answer: D

Rationale: Negligent acts in nursing include various errors that can harm the client, such as medication errors, intravenous therapy errors, burns, falls, failure to use aseptic technique, failure to provide adequate monitoring, and failure to report significant changes in a client's condition. In this scenario, using clean gloves to change a gastrostomy tube dressing is a negligent act because sterile gloves should be used when changing a dressing over broken skin. Choices A, B, and C are not negligent acts as they involve appropriate nursing actions: giving a verbal report, checking neurological signs, and contacting a healthcare provider about a change in a client's blood pressure.

4. Which of the following nursing diagnoses might be appropriate as Parkinson's disease progresses and complications develop?

Correct answer: A

Rationale: The correct answer is 'Impaired Physical Mobility.' As Parkinson's disease progresses, clients may experience a shuffling gait and rigidity, leading to impaired physical mobility. This nursing diagnosis is relevant to address the functional limitations that may arise. 'Dysreflexia' is not typically associated with Parkinson's disease but rather with spinal cord injuries. 'Hypothermia' is a condition of abnormally low body temperature and is not a common complication of Parkinson's disease. 'Impaired Dentition' refers to dental issues and is not directly related to the progression of Parkinson's disease.

5. A new nurse employed at a community hospital is reading the organization's mission statement. The new nurse understands that this statement is written for which purpose?

Correct answer: A

Rationale: The correct answer is 'To outline what the organization plans to accomplish.' A mission statement expresses the purpose or reason for an organization's existence, outlining what it aims to achieve. It often includes statements of philosophy, purpose, and goals. This statement serves as a benchmark for evaluating the organization's performance. The mission statement is not meant to identify policies and procedures (Choice B) or describe employee benefits (Choice C). Choice B specifies the administrative guidelines and protocols of the organization, while Choice C pertains to the perks available to employees. Choice D is incorrect as the rules of the organization that employees must follow are usually detailed in employee handbooks or codes of conduct, not in the mission statement.

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