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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: 6 liters/minute
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 nurse is interviewing an older adult while assisting with data collection. Which client comment regarding vision requires immediate discussion with the health care provider?
- A. "If I go from a very bright room to a very dark room, I have some trouble adjusting."
- B. "I have to hold my newspaper farther and farther away from me when I read."
- C. "I have a little trouble telling if my same-colored shirts and blouses actually match; the colors seem the same to me."
- D. "It looks like I have a blank spot in the middle of what I’m trying to see."
Correct answer: "It looks like I have a blank spot in the middle of what I’m trying to see."
Rationale: The correct answer is "It looks like I have a blank spot in the middle of what I’m trying to see." Seeing blank spots in the middle of an object is a sign of central vision loss, which is a symptom of macular degeneration. Macular degeneration is a serious condition that requires immediate discussion with a healthcare provider to prevent further vision loss. Choice A, mentioning difficulty adjusting between bright and dark rooms, is a common issue related to changes in lighting and not a cause for immediate concern. Choice B, having to hold objects farther away when reading, is indicative of presbyopia, a normal age-related change in vision. Choice C, experiencing slight changes in color perception, is also a common age-related change and not an urgent issue that necessitates immediate discussion with a healthcare provider.
3. A nurse assisting with data collection of a client gathers both subjective and objective data. Which finding would the nurse document as subjective data?
- A. The client appears anxious.
- B. Blood pressure is 170/80 mm Hg.
- C. The client states that he has a rash.
- D. The client has diminished reflexes in the legs.
Correct answer: The client states that he has a rash.
Rationale: Subjective data are information provided by the client about their symptoms, feelings, or experiences. In this case, the client reporting having a rash is subjective data because it is based on what the client says. Choices A, B, and D involve observations or measurements made by the nurse (anxious appearance, blood pressure, reflexes), which fall under objective data. Objective data are observable and measurable data obtained through physical examination, vital signs assessment, and laboratory tests.
4. If Ms. Barrett’s distance vision is 20/30, which of the following statements is true?
- A. The client can read from 20' what a person with normal vision can read at 30'.
- B. The client can read from 30' what a person with normal vision can read at 20'.
- C. The client can read the entire chart from 30'.
- D. The client can read the chart from 20' with the left eye and from 30' with the right eye.
Correct answer: The client can read from 20' what a person with normal vision can read at 30'.
Rationale: When Ms. Barrett's distance vision is measured as 20/30, it means that she can read from 20 feet away what a person with normal vision can read at 30 feet. The numerator (20) represents the distance in feet between the chart and the client, while the denominator (30) indicates the distance at which a normal eye can read the chart. In this case, Ms. Barrett's vision is slightly worse than normal, as she needs to be closer to the chart to read it clearly. Therefore, choice A is correct. Choices B, C, and D are incorrect: Choice B reverses the distances, Choice C assumes the client can read the entire chart from 30 feet, and Choice D introduces information not related to the 20/30 measurement.
5. James returns home from school angry and upset because his teacher gave him a low grade on an assignment. After returning home from school, he kicks the dog. This coping mechanism is known as:
- A. denial
- B. suppression
- C. displacement
- D. fantasy
Correct answer: C
Rationale: The correct answer is 'displacement.' Displacement is a defense mechanism where emotions or impulses are transferred from their original source to a substitute target. In this scenario, James is displacing his anger from his teacher onto the dog. Choice A, 'denial,' involves refusing to acknowledge an unpleasant reality. Choice B, 'suppression,' is the conscious effort to push unwanted thoughts out of awareness. Choice D, 'fantasy,' refers to imagining scenarios that fulfill one's desires but are not based in reality.
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