NCLEX-PN
NCLEX PN Test Bank
1. The nurse is teaching a client about erythema infectiosum. Which of the following factors is not correct?
- A. There is no rash.
- B. The disorder is uncommon in adults.
- C. There is no fever.
- D. There is sometimes a 'slapped face' appearance.
Correct answer: B
Rationale: The correct answer is B: 'The disorder is uncommon in adults.' Erythema infectiosum, also known as Fifth's disease, is more common in children than in adults. It typically presents with a rash on the face that gives a 'slapped cheek' or 'slapped face' appearance. Fever may be present, and there is a characteristic rash associated with the condition. Therefore, the statement 'The disorder is uncommon in adults' is incorrect, making it the correct answer. The other statements are true regarding erythema infectiosum, making them incorrect choices. There is indeed a rash associated with erythema infectiosum, which can be a prominent feature. Fever may also be present in individuals with this condition. Additionally, the 'slapped face' appearance is a classic characteristic of erythema infectiosum.
2. An 85-year-old client is eligible for Medicare-reimbursable home care services. Referral is contingent on meeting which of the following criteria?
- A. homebound status, requiring skilled therapy care
- B. immediate previous hospitalization for acute care
- C. age
- D. requirement of nursing and social work support
Correct answer: A
Rationale: The correct criteria for Medicare-reimbursable home care services include the client being homebound and requiring a skilled service, such as physical therapy, occupational therapy, speech therapy, nursing, or social work. Choice A is correct because it aligns with these requirements. Choice B is incorrect as immediate previous hospitalization is not a prerequisite for home care services. Choice C is incorrect as age alone does not determine eligibility for Medicare-reimbursable home care services. Choice D is incorrect as the requirement of nursing and social work support alone is not sufficient for Medicare-reimbursable home care services.
3. When a client needs oxygen therapy, what is the highest flow rate that oxygen can be delivered via nasal cannula?
- A. 2 liters/minute
- B. 4 liters/minute
- C. 6 liters/minute
- D. 8 liters/minute
Correct answer: C
Rationale: The correct answer is 6 liters/minute. When a client requires oxygen therapy, the maximum flow rate that oxygen can be delivered via nasal cannula is 6 liters/minute. Nasal cannula can effectively deliver oxygen up to 6 liters/minute. Flow rates exceeding 6 liters/minute may lead to drying of the nasal passages and discomfort for the client. Higher flow rates, like 8 liters/minute, should be administered using a mask to ensure sufficient oxygenation. Options A, B, and D are incorrect as they indicate flow rates that surpass the recommended maximum for nasal cannula delivery.
4. A nurse planning care for her assigned clients understands that which aspect is the purpose of the hospital's standards of care?
- A. Identify methods of treatment.
- B. Provide direction for care based on the client's diagnosis.
- C. Identify new care methods based on current medical research.
- D. Provide direction for the practice of nursing
Correct answer: D
Rationale: The purpose of the hospital's standards of care is to provide a broad direction for the overall practice of nursing that applies to all nursing situations, across specialty areas, and across the country. These standards guide the practice of nursing by outlining the expected level of care and professional performance. While identifying methods of treatment is important, it is usually specific to individual client needs and not the overarching goal of standards of care. Providing direction for care solely based on the client's diagnosis is limited to a particular patient's treatment plan and does not encompass the broader scope of nursing practice. Identifying new care methods based on current medical research is essential for advancing healthcare practices but is not the primary purpose of the hospital's standards of care.
5. A graduate nurse hired to work in a medical unit of a hospital is attending an orientation session. The nurse educator, discussing care maps, asks the graduate nurse whether she understands how a care map is used. Which response indicates understanding?
- A. The care map outlines the day-to-day expected outcomes of care and the outcomes anticipated at discharge
- B. The care map is a plan that is used only by the nurse to provide client care
- C. The care map is a standard plan, rather than an individualized one, that is developed strictly by a nurse and used for a client with a particular diagnosis
- D. The care map is developed by a nurse and identifies nursing diagnoses
Correct answer: A
Rationale: The correct answer is A. A care map, also known as a critical pathway, outlines the day-to-day expected outcomes of care and the outcomes anticipated at discharge or the end of a treatment phase. It includes clinical assessments, treatments, dietary interventions, activity therapies, client education, and discharge planning. While it may identify nursing diagnoses, a care map is developed by all disciplines caring for the client type and is used by the interdisciplinary team, not just the nurse alone. Choice B is incorrect because a care map is not solely for the nurse but for the entire interdisciplinary team. Choice C is incorrect as care maps are individualized plans developed by the interdisciplinary team, not just by a nurse. Choice D is incorrect as a care map is not solely about nursing diagnoses but encompasses a comprehensive plan of care.
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