NCLEX-PN
NCLEX PN Test Bank
1. The nurse belongs to a professional nursing organization that provides social, educational, and political venues for nurses. The nurse has been active in this organization for almost two years, during which time she meets and works with nurses from several different nursing agencies and health care institutions to achieve a variety of goals, including obtaining advice regarding a personal career choice. This is an example of:
- A. professional nurturing.
- B. networking.
- C. mentoring.
- D. collegiality.
Correct answer: B
Rationale: Networking involves the process of developing and using contacts throughout one's professional career for information, advice, and support. In this scenario, the nurse is actively engaging with other professionals from various institutions to achieve common goals and seek career advice, which aligns with the concept of networking. Professional nurturing and mentoring focus on providing support and guidance to colleagues, while collegiality refers to the camaraderie and rapport established among individuals through shared experiences, which is not the primary focus of the nurse's interaction in the given situation.
2. Which is an appropriate outcome for the nursing diagnosis of Body Image Disturbance for a client with anorexia nervosa?
- A. The client verbalizes knowledge of a maintenance diet.
- B. The client demonstrates assertiveness with family.
- C. The client verbalizes her body size accurately.
- D. The client demonstrates control of obsessive behaviors.
Correct answer: C
Rationale: The correct answer is 'The client verbalizes her body size accurately.' For clients with anorexia nervosa, body image disturbance is a common issue where they perceive themselves inaccurately. Verbalizing her body size accurately indicates progress towards correcting this distorted self-perception. Choices A, B, and D are incorrect because they do not directly address the distorted body image perception seen in clients with anorexia nervosa. Choice A focuses on knowledge of a maintenance diet, which is unrelated to body image perception. Choice B involves assertiveness with family, which is more related to family dynamics. Choice D addresses control of obsessive behaviors, which is not directly related to correcting the distorted body image perception.
3. The nurse is preparing task assignments for the day. Which task should the nurse assign to a nursing assistant?
- A. Monitoring for bleeding for a client who has just undergone cardiac catheterization
- B. Assisting a client who is getting up to ambulate for the first time after surgery
- C. Providing oral care to an unconscious client who requires oral care
- D. Completing the preoperative checklist for a client scheduled for a liver biopsy
Correct answer: C
Rationale: When delegating tasks, the nurse must consider the state nursing practice act guidelines and job descriptions. Providing oral care to an unconscious client is a task suitable for delegation to a nursing assistant. The nurse should give clear instructions on adapting the procedure for the client's needs and the signs of complications to watch for. Monitoring for bleeding after cardiac catheterization necessitates immediate nursing assessment, which requires critical thinking and intervention that exceeds a nursing assistant's scope of practice. Assisting a client with ambulation post-surgery carries the risk of orthostatic hypotension and should be performed by a licensed nurse. Completing a preoperative checklist for a client scheduled for a liver biopsy involves critical assessment and preparation that are within the nurse's scope of practice.
4. A client is having a seizure; his blood oxygen saturation drops from 92% to 82%. What should the nurse do first?
- A. Open the airway.
- B. Administer oxygen.
- C. Suction the client.
- D. Check for breathing.
Correct answer: A
Rationale: When a client is having a seizure and their blood oxygen saturation drops significantly, the priority action for the nurse is to open the airway. This allows for adequate oxygenation and ventilation. Administering oxygen can come after ensuring the airway is clear. Suctioning the client should be done if there is an airway obstruction, and checking for breathing is part of the assessment but opening the airway takes precedence to ensure proper oxygenation and ventilation during a critical event like a seizure.
5. A client who is immobilized secondary to traction is complaining of constipation. Which of the following medications should the nurse expect to be ordered?
- A. Advil
- B. Anasaid
- C. Clinocil
- D. Colace
Correct answer: D
Rationale: Colace is a stool softener that acts by pulling more water into the bowel lumen, making the stool soft and easier to evacuate. In the given scenario of constipation in an immobilized client, a stool softener like Colace is the appropriate choice to help facilitate bowel movements. Advil and Anasaid are nonsteroidal anti-inflammatory drugs (NSAIDs) used for pain relief, not for constipation. Clinocil is not a recognized medication for constipation relief.
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