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. Which of the following is an appropriate nursing goal for a client at risk for nutritional problems?
- A. provide oxygen
- B. promote healthy nutritional practices
- C. treat complications of malnutrition
- D. increase weight
Correct answer: B
Rationale: The correct answer is to promote healthy nutritional practices. This goal focuses on preventive measures to address the client's nutritional risk. Providing oxygen (Choice A) is not directly related to addressing nutritional problems. Treating complications of malnutrition (Choice C) involves addressing the consequences rather than preventing or managing the nutritional problems. Increasing weight (Choice D) would only be appropriate if the client is underweight; it does not address the broader aspect of promoting overall healthy nutritional practices.
3. Which of the following lab values is elevated first after a client has a myocardial infarction?
- A. LDH
- B. troponin
- C. CPK
- D. SGOT
Correct answer: B
Rationale: The correct answer is troponin. Troponin levels are the most specific and sensitive markers for myocardial infarction, and they begin to rise within a few hours after the event. CPK, SGOT, and LDH are also enzymes that can indicate myocardial damage, but troponin is the earliest and most specific indicator. CPK typically rises 4-8 hours after an infarction, followed by SGOT (AST) at 8-12 hours, and LDH at 12-24 hours post-infarction.
4. When the healthcare provider is determining the appropriate size of a nasopharyngeal airway to insert, which body part should be measured on the client?
- A. corner of the mouth to tragus of the ear
- B. corner of the eye to top of the ear
- C. tip of the chin to the sternum
- D. tip of the nose to the earlobe
Correct answer: D
Rationale: A nasopharyngeal airway is measured from the tip of the nose to the earlobe. This measurement ensures that the airway is of the correct length to reach the nasopharynx without being too long or too short. Choices A, B, and C are incorrect as they do not provide the appropriate measurement for selecting the correct size of a nasopharyngeal airway. The distance from the corner of the mouth to the tragus of the ear (Choice A) is used to measure for an oropharyngeal airway, not a nasopharyngeal airway. Similarly, the other choices (B and C) do not correlate with the correct measurement of a nasopharyngeal airway.
5. The nurse teaching a client about hepatitis and its transmission should explain that one type of hepatitis does not produce a carrier state after its acute phase. Which type is it?
- A. hepatitis A
- B. hepatitis B
- C. hepatitis C
- D. hepatitis D
Correct answer: A
Rationale: The correct answer is hepatitis A. Hepatitis A does not produce a carrier state after its acute phase. It is transmitted via contaminated water or food through the oral-fecal route and is not blood-borne. Hepatitis B, choice B, can lead to a carrier state where the person remains infectious despite being asymptomatic. Hepatitis C, choice C, can also result in a chronic carrier state. Hepatitis D, choice D, is an incomplete virus that requires hepatitis B to replicate; it does not lead to a carrier state on its own.
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