NCLEX-PN
Nclex PN Questions and Answers
1. During an emergency procedure, is the surgical timeout a requirement?
- A. The surgical timeout should be performed by the surgical team unless it would cause a delay leading to injury or death.
- B. No, the timeout is not necessary during an emergency procedure.
- C. No, the surgical timeout is not required in emergency procedures.
- D. Yes, the surgical timeout must be performed in all cases.
Correct answer: A
Rationale: During an emergency procedure, the surgical timeout should be performed unless doing so would cause a delay leading to injury or death. This is because the primary goal during an emergency is to swiftly address the critical situation. Choice B is incorrect as it implies that the timeout is not necessary, which is not accurate. Choice C is also incorrect as it suggests that the timeout is not required in emergency procedures, disregarding safety protocols. Choice D is incorrect as it wrongly states that the timeout must be performed in all cases without considering the potential risks associated with delays during emergencies.
2. When are standard walkers typically used?
- A. When clients have poor balance, cannot stand up, have weak arms, and good hand strength.
- B. When clients have poor balance, have a broken leg, or have experienced amputation.
- C. When clients have poor balance, have cardiac problems, or cannot use crutches or a cane.
- D. When clients have poor balance, have an autoimmune disease, or have weak arms.
Correct answer: C
Rationale: Standard walkers are typically used for clients who have poor balance, cardiac problems, or those who cannot use crutches or a cane. The rationale is correct in stating that a walker is suitable for individuals needing to bear partial weight and having strength in their wrists and arms to propel the walker forward. Choices A, B, and D are incorrect because they do not accurately reflect the main reasons why standard walkers are used in clinical practice. Using a walker is not solely about having weak arms, good hand strength, a broken leg, experienced amputation, or an autoimmune disease. The primary focus is on addressing balance issues, cardiac problems, or the inability to use crutches or a cane effectively.
3. Which of the following isoenzymes is elevated in a client who has had a myocardial infarction?
- A. CPK-BB
- B. CPK-MM
- C. CPK-MB
- D. CPK-MI
Correct answer: C
Rationale: CPK-MB is the correct answer as it is elevated in clients who have had a myocardial infarction. CPK-BB is elevated in clients with brain damage, and CPK-MM is elevated in clients with skeletal muscle damage. CPK-MI, mentioned in the rationale, does not exist, making it an incorrect choice.
4. After administering medication through an NG tube, the client asks if he can lie down when the nurse leaves the room. What is the most appropriate response?
- A. You can lie down in 1 hour.
- B. You can lie down in 5 minutes if your NG residual is below 50 mLs.
- C. You can lie down in about 30 minutes.
- D. Yes, feel free to lie down.
Correct answer: C
Rationale: The correct answer is to inform the client that they can lie down in about 30 minutes. After administering medication through an NG tube, it is recommended that the client remains upright for about 30 minutes to ensure proper absorption of the medications. Option A is incorrect as waiting for 1 hour is unnecessary. Option B is incorrect as the specified timeframe and condition given are not standard practice for lying down after NG tube medication administration. Option D is incorrect as it lacks guidance on the appropriate waiting time and does not emphasize the importance of waiting before lying down for optimal medication absorption.
5. The nurse is transferring a client from a wheelchair to the bed. Which is the correct procedure?
- A. Pull the client toward you, and pivot him on the unaffected limb.
- B. Pull the client toward you, and pivot him on the affected limb.
- C. Push the client toward the bed, and pivot him on the affected limb.
- D. Stand the client on both legs, and push him toward the bed.
Correct answer: A
Rationale: When transferring a client from a wheelchair to the bed, the correct procedure is to pull the client toward you, which reduces workload force. By pivoting the client on the unaffected limb, strength is maintained to support the affected limb while moving towards the bed. Choice A is correct because it ensures a safe and effective transfer technique. Choices B, C, and D are incorrect as they involve incorrect positioning and movements that could potentially harm the client or increase the risk of injury. Pulling the client towards you puts less strain on your back and reduces the risk of injury. Pivoting on the unaffected limb ensures better support for the client's affected limb during the transfer process.
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