NCLEX-PN
NCLEX PN Test Bank
1. The nurse should teach parents of small children that the most common type of first-degree burn is:
- A. scalding from hot bath water or spills
- B. contact with hot surfaces such as stoves and fireplaces
- C. contact with flammable liquids or gases resulting in flash burns
- D. sunburn from lack of protection and overexposure
Correct answer: D
Rationale: The most common type of first-degree burn in small children is sunburn, often due to lack of protection and overexposure to the sun. This type of burn highlights the importance of educating parents about using sunscreens and ensuring children are adequately protected from the sun's harmful rays. Choices A, B, and C describe scenarios that can lead to burns but are not the most common type of first-degree burn in small children, making them incorrect.
2. Which of these statements from the caregiver of a palliative care client indicates a proper understanding?
- A. This treatment plan usually indicates a prognosis of less than 6 months.
- B. We will need to stay in the hospital to receive this level of care.
- C. The main therapeutic goals are comfort and better quality of life.
- D. The medications to treat the underlying disease will be continued.
Correct answer: C
Rationale: The correct answer is 'The main therapeutic goals are comfort and better quality of life.' This statement reflects a proper understanding of palliative care, which focuses on improving the patient's quality of life and providing comfort. It does not necessarily mean a prognosis of less than 6 months or require hospitalization. Choice A is incorrect because palliative care can be provided regardless of the prognosis. Choice B is wrong as palliative care can be administered in various settings, not just hospitals. Choice D is inaccurate as palliative care aims to improve symptoms and quality of life, so medications may be adjusted but not necessarily stopped.
3. A nursing care plan for a client with sleep problems has been implemented. All of the following should be expected outcomes except:
- A. the client reports no episodes of awakening during the night.
- B. the client falls asleep within 1 hour of going to bed.
- C. the client reports satisfaction with their amount of sleep.
- D. the client rates sleep as an 8 or more on the visual analog scale.
Correct answer: B
Rationale: An expected outcome for a nursing care plan targeting sleep problems is that the client reports no episodes of awakening during the night, the client reports satisfaction with their amount of sleep, and the client rates sleep as an 8 or more on the visual analog scale. Falling asleep within 1 hour of going to bed is not necessarily an expected outcome. While it is generally desirable for individuals to fall asleep within a reasonable time frame, this specific timeframe may vary among individuals, and it is not a strict criterion for successful sleep outcomes. Therefore, the correct answer is that the client falls asleep within 1 hour of going to bed, as this is not a definitive measure of the effectiveness of the nursing care plan for sleep problems.
4. When a physician removes a chest tube, which type of dressing is recommended to be placed over the site?
- A. transparent dressing
- B. colloidal dressing
- C. petrolatum gauze
- D. nonadherent dressing
Correct answer: C
Rationale: Petrolatum gauze is recommended to be placed over the site when a physician removes a chest tube because it forms an airtight seal, helping prevent air from entering the pleural space. This airtight seal is crucial to avoid complications such as a pneumothorax. Transparent dressing is not ideal for this purpose as it may not provide a sufficient seal due to its design. Colloidal dressing and nonadherent dressing are also not suitable for chest tube removal sites as they do not offer the same level of protection against air leakage and may not provide the necessary sealing properties.
5. The client with a diagnosis of hepatitis is experiencing pruritus. Which would be the most appropriate nursing intervention?
- A. Suggest that the client take warm showers once a day.
- B. Add baby oil to the client's bath water.
- C. Apply powder to the client's skin.
- D. Suggest a cool-water rinse after bathing.
Correct answer: B
Rationale: Pruritus, or itching, in clients with hepatitis can be alleviated by adding moisturizing agents to bath water. Baby oil helps soothe and moisturize the skin, reducing dryness and itching. Warm showers, as in choice A, can be drying to the skin if taken too frequently, making it less suitable than adding oil to the bath water. Applying powder, as mentioned in choice C, can exacerbate dryness rather than alleviate it. Choice D suggests a cool-water rinse after bathing, which can help in retaining moisture and is less drying compared to hot water rinses.
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