the nurse is caring for a client recovering from a stroke who recently regained consciousness the client is having difficulty communicating verbally w the nurse is caring for a client recovering from a stroke who recently regained consciousness the client is having difficulty communicating verbally w
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Nursing Elites

NCLEX NCLEX-PN

Nclex PN Questions and Answers

1. The nurse is caring for a client recovering from a stroke who recently regained consciousness. The client is having difficulty communicating verbally with the team. Which of the following actions would be least appropriate?

Correct answer: C: Wait for the physician's order for speech therapy before assisting with the appropriate documentation.

Rationale: In this scenario, the least appropriate action would be to wait for the physician's order for speech therapy before assisting with the appropriate documentation. The nurse should start by collecting client data without needing the physician's order, use documents to provide information for the referral, and actively participate in the client referral process. Waiting for the physician's order unnecessarily delays potentially crucial therapy for the client's recovery, affecting the timeliness and effectiveness of care. Therefore, choice C is the least appropriate as immediate action is required in such situations.

2. Mrs. Owens is the 81-year-old mother of Jonathan, who is 54 years old. Jonathan has had schizophrenia since he was 16 years old. Which of Mrs. Owens’s concerns is likely to predominate?

Correct answer: “What will become of Jonathan when I am gone?”

Rationale: The most prominent concern for Mrs. Owens is likely what will happen to her son, Jonathan, after she passes away. While retirement fund sustainability is important, it is not likely to be her primary concern. Funeral arrangements, although significant, are secondary to the welfare of her son with schizophrenia. The question of how to communicate with Jonathan's physician is less likely to be a predominant concern since Mrs. Owens has likely already addressed this issue over the 38 years of managing her son's care.

3. A safety measure to implement when transferring a client with hemiparesis from a bed to a wheelchair is:

Correct answer: moving the wheelchair close to the client’s bed and standing and pivoting the client on his unaffected extremity to the wheelchair.

Rationale: When transferring a client with hemiparesis from a bed to a wheelchair, it is crucial to ensure their safety. The correct safety measure involves moving the wheelchair close to the client’s bed and having the client stand and pivot on his unaffected extremity to the wheelchair. This method provides support with the unaffected limb, reducing the risk of falls and promoting a safer transfer. Choice A is incorrect because walking the client is unsafe and not recommended. Choice C is incorrect as pivoting the client on his affected extremity can lead to injury or falls due to weakness or lack of control. Choice D is incorrect as it puts the client at risk by requiring them to push their body, which may not be feasible or safe for someone with hemiparesis.

4. What is the threshold of dextrose concentrations that can safely be administered through a peripheral IV?

Correct answer: Dextrose concentrations below 10% can be safely administered through a peripheral IV; dextrose concentrations above 10% should not be administered through a peripheral IV.

Rationale: Dextrose concentrations below 10% are considered safe for administration through a peripheral IV, as concentrations above this threshold can lead to phlebitis, causing inflammation of the vein. Concentrations above 10% should not be administered through a peripheral IV to prevent vein irritation. Choice A is incorrect because concentrations above 20% are too high for a peripheral IV. Choice B is incorrect as dextrose concentrations below 5% are too low to be effective. Choice D is incorrect because the statement is reversed, suggesting that concentrations above 5% are safe, which is not true.

5. When transferring a client with hemiparesis from a bed to a wheelchair, which safety measure should be implemented?

Correct answer: Moving the wheelchair close to the client’s bed and standing and pivoting the client on their unaffected extremity to the wheelchair

Rationale: When transferring a client with hemiparesis from a bed to a wheelchair, it is crucial to ensure their safety. The correct safety measure is to move the wheelchair close to the client’s bed and have the client stand and pivot on their unaffected extremity to the wheelchair. This method provides support with the unaffected limb, reducing the risk of falls or injuries. Choice A is incorrect as it suggests walking the client, which may not be safe or feasible. Choice C is incorrect because pivoting on the affected extremity can increase the risk of injury. Choice D is incorrect as it does not consider the client's limitations and safety needs, as it involves pushing their body which may not be possible with hemiparesis.

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