NCLEX-PN
Nclex Exam Cram Practice Questions
1. For which of the following conditions might blood be drawn to assess uric acid levels?
- A. asthma
- B. gout
- C. diverticulitis
- D. meningitis
Correct answer: B
Rationale: Uric acid levels are commonly assessed in patients with gout. Gout is a type of arthritis caused by the buildup of uric acid crystals in the joints, leading to inflammation and pain. Monitoring uric acid levels helps in diagnosing and managing gout. Asthma, diverticulitis, and meningitis are not conditions where blood tests for uric acid levels are typically necessary. Asthma is a respiratory condition, diverticulitis involves inflammation of the digestive tract, and meningitis is an infection of the meninges in the brain and spinal cord.
2. Which of these would be the most appropriate way to document a client's refusal of medication?
- A. "Heparin refused during shift. Risks reviewed."?
- B. "The client refused the heparin injection when I tried to administer it. She yelled at me, saying, 'I do not want that injection right now!' and told me to leave the room. I explained the risks of not taking the medication. She seemed very annoyed that I tried to give it at that time. I will attempt again later in my shift."?
- C. "Subcutaneous Heparin injection was attempted to be given to the client per the physician's order. Client refused, stating, 'I do not want that injection.' Potential risks for refusing the medication were reviewed with the client, and the client verbalized understanding."?
- D. "Ct stated she did not want the SQ heparin inj at this time. Risks of not taking this med were reviewed with the ct, and the ct verbalized understanding."?
Correct answer: C
Rationale: The most appropriate way to document a client's refusal of medication should include details such as the medication, the client's statement of refusal, and the review of potential risks. Choice C accurately captures all these essential elements, making it the correct answer. Choice A lacks details about the client's refusal and the review of risks. Choice B includes unnecessary emotional descriptions and a plan of action that might not be appropriate. Choice D uses abbreviations that may not be universally understood, lacks proper punctuation, and also does not provide a detailed account of the refusal and the review of risks.
3. Regardless of their practice area, nurses should be concerned with:
- A. all drug-resistant bacteria.
- B. microorganisms that are critical.
- C. transmission of microorganisms.
- D. overprescription of bacteriostatic drugs.
Correct answer: C
Rationale: All nurses should be concerned with preventing the transmission of microorganisms to themselves and others. A primary way to achieve this is through asepsis. Nursing practice emphasizes providing a safe environment to shield clients, family, and healthcare providers from infections. Choices A, B, and D are incorrect. While drug-resistant bacteria, critical microorganisms, and overprescription of bacteriostatic drugs are important, nurses' primary focus should be on preventing microorganism transmission to ensure safety and well-being.
4. The LPN is checking for residual before administering enteral feeding through a PEG tube. Which of these steps is incorrect?
- A. The LPN elevates the head of the bed by at least 30 degrees.
- B. If the residual is greater than 200mL, the LPN should not administer the enteral feeding.
- C. The LPN should discard the residual before administering the tube feeding.
- D. The residual pH level is tested to ensure appropriate placement.
Correct answer: C
Rationale: The incorrect step is choice C. The residual should be discarded before administering the tube feeding. Discarding the residual is essential to prevent contamination and ensure accurate measurement of the enteral feeding. Elevating the head of the bed by at least 30 degrees (choice A) is correct as it helps prevent aspiration during feeding. Testing the pH level of the residual (choice D) ensures proper placement of the tube. Withholding feeding if the residual is greater than 200mL (choice B) is crucial to prevent overfeeding, making this statement correct.
5. What sign might the nurse observe in a client with a high ammonia level?
- A. coma
- B. edema
- C. hypoxia
- D. polyuria
Correct answer: A
Rationale: Coma is a sign that a nurse might observe in a client with a high ammonia level. Elevated ammonia levels can lead to hepatic encephalopathy, a condition characterized by impaired brain function, which can progress to coma. Edema (choice B) is swelling caused by excess fluid trapped in body tissues, not typically associated with high ammonia levels. Hypoxia (choice C) is a condition of inadequate oxygen supply to tissues and is not directly related to high ammonia levels. Polyuria (choice D) refers to excessive urination and is not a typical sign of high ammonia levels.
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