NCLEX NCLEX-PN
Nclex PN Questions and Answers
1. The nurse is caring for a non-English speaking client. The surgeon has asked the nurse to hurry up and prepare the client for their scheduled procedure, which is running late. Which of the following is least appropriate?
- A. Explain to the client's family member that the procedure may be delayed further.
- B. Inform the surgeon that the procedure will be delayed further because getting a staff interpreter will take additional time.
- C. Allow the client's family member to serve as the interpreter.
- D. Ask if a phone-service interpreting service is available to expedite the client preparation.
Correct answer: Allow the client's family member to serve as the interpreter.
Rationale: Allowing the client's family member to serve as the interpreter is the least appropriate option. It is not recommended to rely on family members for interpretation as they may not be impartial, accurate, or trained to handle sensitive medical information. This can lead to misunderstandings, breaches in confidentiality, and compromised care. Choice A is a better option as it involves communication with the family member to manage expectations. Choice B is also appropriate as it prioritizes the need for a professional interpreter to ensure accurate communication. Choice D is a valid option as it explores the possibility of using a phone-service interpreting service to facilitate communication efficiently.
2. Which of the following is not one of the three universal spiritual needs?
- A. meaning and purpose
- B. love and relatedness
- C. forgiveness
- D. God's permission
Correct answer: God's permission
Rationale: The three universal spiritual needs are meaning and purpose, love and relatedness, and forgiveness. These needs are commonly recognized across various belief systems and cultures. While the concept of God may be central to many religions, 'God's permission' is not considered a universal spiritual need. Seeking 'God's permission' is more specific to certain religious practices rather than a universally acknowledged spiritual need. Therefore, the correct answer is 'God's permission.' Choices A, B, and C are correct as they align with the generally accepted universal spiritual needs.
3. A patient 3 hours post-op from a hysterectomy is complaining of intense pain at the incision site. When assessing the patient, the nurse notes a BP of 169/93, pulse 145 bpm, and regular. What action should the nurse take?
- A. Reassure the patient that pain is normal following surgery.
- B. Administer prn Nifedipine and assess the client’s response.
- C. Administer prn Meperidine HCL and assess the client’s response.
- D. Recheck BP and pulse rate every 20 minutes for the next hour.
Correct answer: Administer prn Meperidine HCL and assess the client’s response.
Rationale: The correct action for the nurse to take in this situation is to administer prn Meperidine HCL and assess the client's response. A BP of 169/93 and a pulse of 145 bpm indicate pain-related hypertension and sinus tachycardia, which are physiological responses to pain. Treating the cause of the increased pulse rate requires pain medication. Reassuring the patient about normal post-surgery pain is important, but addressing the physiological responses to pain is a priority. Administering Nifedipine, a calcium channel blocker, is not indicated for pain management but for hypertension. Rechecking the BP and pulse rate without addressing the pain directly does not address the underlying issue causing the elevated vital signs.
4. Which system is primarily affected by tuberculosis (Mycobacterium)?
- A. stomach (GI)
- B. heart (cardiac)
- C. lungs (respiratory)
- D. skin (integumentary)
Correct answer: C
Rationale: Tuberculosis, caused by Mycobacterium tuberculosis, primarily affects the respiratory system. This aerobic bacillus thrives in highly oxygenated body sites, such as the lungs, growing ends of bones, and the brain. The bacillus is airborne, making the lungs a common site for infection. Choices A, B, and D are incorrect as tuberculosis predominantly impacts the respiratory system and rarely involves the stomach, heart, or skin.
5. What is involved in client education by the nurse?
- A. Telling the client everything about their disease, what will happen in the course of the disease, and the outcome.
- B. Giving information to the client that is accurate and understandable.
- C. Informing the client that the pain they experience might not be real.
- D. Administering medication to the client when they experience pain.
Correct answer: Giving information to the client that is accurate and understandable.
Rationale: Client education by the nurse involves providing accurate and understandable information to the client. It is essential to offer relevant details without overwhelming them, making choice B the correct answer. Choice A is incorrect because providing excessive details can confuse the client rather than empower them with necessary knowledge. Choice C is incorrect as it is not the role of the nurse to question the reality of a client's pain; instead, they should address and manage the pain effectively. Choice D is incorrect as client education focuses on providing information and empowering clients with knowledge, not just administering medication.
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