NCLEX-PN
NCLEX PN Test Bank
1. 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.
2. 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.
3. A nurse discusses staff empowerment with the nursing team. The nurse explains that staff empowerment has which function?
- A. Fosters the growth of others so that they are less dependent on the leader
- B. Means that the staff has the power to reprimand and punish any individual who is not meeting the standards of care delivery
- C. Indicates that the nurse leader will make decisions regarding the nursing unit and expects that the staff will comply with the changes
- D. Allows the staff to make every decision regarding employee scheduling
Correct answer: A
Rationale: Staff empowerment fosters the growth of others and facilitates their development so that they are less dependent on their leader. This empowerment is about enhancing skills and autonomy, not about reprimanding or punishing others (Choice B). Empowerment involves shared decision-making and autonomy, not unilateral decision-making by the leader (Choice C). Moreover, staff empowerment does not mean that staff should make every decision regarding operational aspects like employee scheduling (Choice D). It is primarily focused on developing individuals' capabilities and fostering independence within the team.
4. What should a client room environment include?
- A. a made bed, fresh water, thermostat regulation, and clean floors in all occupied client areas.
- B. a made bed, comfort and safety, a clutter-free area, hygiene articles nearby.
- C. accident prevention, comfort, a room (including furniture) that has been cleaned with chloroseptic wash, a bed that is made every other day.
- D. odor control (by spraying the room with deodorizers), closet storage of all client objects, a clean room. (Gloves should be worn when cleaning.)
Correct answer: B
Rationale: A client room environment should include a made bed to provide a sense of neatness and comfort, ensuring the client's safety at all times. It is important to maintain a clutter-free area to prevent accidents and promote a relaxing environment. Having hygiene articles nearby allows the client easy access to personal care items. Choice A is incorrect because while fresh water and thermostat regulation are important, they are not essential components of a client room environment. Choice C is incorrect as it emphasizes more on cleaning procedures rather than creating a comfortable and safe environment for the client. Choice D is incorrect as it emphasizes odor control and storage rather than the client's comfort and safety.
5. A client who had a stroke has left-side weakness and is having difficulty holding utensils while eating. To which of these services does the nurse suggest a referral?
- A. Physical therapy
- B. Occupational therapy
- C. Home care
- D. Social services
Correct answer: B
Rationale: An occupational therapist assists clients with impairments in performing activities of daily living, such as feeding themselves with the use of adaptive devices. In this case, the client needs help with holding utensils while eating, falling under the scope of occupational therapy. Home care provides general support services but doesn't specifically address the client's need for utensil use. Social services focus on counseling and financial aspects of care, not physical rehabilitation like occupational therapy does. Physical therapy primarily deals with physical disabilities through exercises, which is not the primary concern for the client's difficulty in holding utensils.
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