NCLEX-PN
Nclex PN Questions and Answers
1. What type of injury is associated with acute hyphema?
- A. orthopedic
- B. eye
- C. insect sting or snakebite
- D. gynecological trauma
Correct answer: B
Rationale: Acute hyphema is associated with an eye injury, typically resulting from blunt trauma. The presence of blood in the anterior chamber of the eye causes a half-moon appearance or a horizontal line across the globe when the client is upright. Choices A, C, and D are incorrect because acute hyphema is not related to orthopedic injuries, insect stings, snakebites, or gynecological trauma.
2. A discharge planning nurse is making arrangements for a client with an epidural catheter for continuous infusion of opioids to be placed in a long-term care facility. The family prefers a facility in its neighborhood to facilitate visiting. The neighborhood facility has never cared for a client with this type of need. What is the most appropriate action by the discharge planning nurse?
- A. Arrange for immediate in-services for the long-term care facility staff on pain management using epidural catheters.
- B. Explain the situation to the client and family and seek another long-term care facility for discharge from the hospital.
- C. Encourage the family to hire private duty nurses skilled in epidural catheter pain management to allow the client to be transferred to the neighborhood facility.
- D. None of the above
Correct answer: B
Rationale: In this scenario, the priority is the safety and well-being of the client. The neighborhood facility's lack of experience in caring for a client with an epidural catheter for continuous opioid infusion raises concerns about the quality of care they can provide. Therefore, the most appropriate action for the discharge planning nurse is to explain the situation to the client and family and seek another long-term care facility that can provide the necessary care. Option A, arranging for immediate in-services, may not be feasible or timely, considering the urgent need for appropriate care. Option C, encouraging the family to hire private duty nurses, does not ensure the facility's overall capability to manage the client's complex needs. Option D, 'None of the above,' is not the best choice as the client's safety should be the priority in this situation.
3. The nurse is working the same shift two days in a row. On the first of these days, while caring for one assigned client, the client says, "Will you promise me you will be my nurse tomorrow?"? Which response is most appropriate?
- A. "Yes, I promise you I will be your nurse during my shift tomorrow."?
- B. "You will need to speak to my supervisor about this request."?
- C. "While I cannot promise that I will be your nurse tomorrow, I can talk to the charge nurse about this request."?
- D. "Because of confidentiality, I cannot discuss tomorrow's assignments with you."?
Correct answer: D
Rationale: The most appropriate response is to maintain confidentiality regarding work assignments. It is crucial to uphold patient privacy and not disclose information about staff schedules or assignments. Choices A, B, and C involve promising or redirecting the patient, which is not suitable in this situation. Choice D respects confidentiality and is the most professional response in this scenario.
4. When assessing a client's risk for elimination impairment, which of the following factors is least relevant?
- A. current medications
- B. ambulation abilities
- C. family history
- D. hydration status
Correct answer: C
Rationale: When assessing a client's risk for elimination impairment, family history is the least relevant factor to consider. Current medications can affect elimination functions through side effects, ambulation abilities can impact mobility to access toileting facilities, and hydration status directly influences urinary output and bowel function. Family history, although providing some context, does not have a direct impact on the client's current risk of elimination impairment.
5. What is the purpose of the hydraulic lift (Hoyer lift)?
- A. To assist clients who have had orthopedic surgery.
- B. To assist clients who are unable to stand and extremely obese clients.
- C. To assist clients of all ages in a hospital setting.
- D. To assist clients with special needs.
Correct answer: B
Rationale: The purpose of the hydraulic lift, also known as the Hoyer lift, is to facilitate safe transfers for clients who cannot stand or are extremely obese. It is specifically designed for assisting clients who are unable to stand and for those who are too heavy for healthcare workers to lift safely. Choice A is incorrect because the primary purpose of a hydraulic lift is not related to orthopedic surgery. Choice C is incorrect because it is too broad and does not capture the specific use of the hydraulic lift. Choice D is incorrect because the lift is not solely for clients with special needs but rather for those who cannot stand or are extremely obese.
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