which assignment should not be performed by the licensed practical nurse

NCLEX-PN

PN Nclex Questions 2024

1. Which task should not be performed by the licensed practical nurse?

A. Inserting a Foley catheter
B. Discontinuing a nasogastric tube
C. Obtaining a sputum specimen
D. Initiating a blood transfusion

Correct answer: D

Rationale: A licensed practical nurse should not initiate a blood transfusion. LPNs can assist with transfusions and verify ID numbers but should not be assigned to initiate the procedure. Inserting Foley catheters, discontinuing nasogastric tubes, and obtaining sputum specimens are within the scope of practice for LPNs. Therefore, options A, B, and C are tasks that LPNs can perform, making them incorrect choices.

2. The doctor orders 2% nitroglycerin ointment in a 1-inch dose every 12 hours. Proper application of nitroglycerin ointment includes:

A. Rotating application sites
B. Limiting applications to the chest
C. Rubbing it into the skin
D. Covering it with a thin paper dressing

Correct answer: A

Rationale: Proper application of nitroglycerin ointment involves rotating application sites to prevent skin irritation. It should be applied to the back and upper arms, not restricted to the chest, making option B incorrect. Rubbing it into the skin, as indicated in option C, is not recommended for nitroglycerin ointment as it can lead to faster absorption and potential side effects. The correct way is to cover it with a thin paper dressing, not gauze as mentioned in option D, to ensure proper absorption and prevent the medication from evaporating too quickly.

3. A 26-year-old single woman is knocked down and robbed while walking her dog one evening. Three months later, she presents at the crisis clinic, stating that she cannot put this experience out of her mind. She complains of nightmares, extreme fear of being outside or alone, and difficulty eating and sleeping. What is the best response by the nurse?

A. "I will ask the physician to prescribe medication for you."?
B. "That must have been a very difficult and frightening experience. It might be helpful to talk about it."?
C. "In the future, you might walk your dog in a more populated area or hire someone else to take over this task."?
D. "Have you thought of moving to a safer neighborhood?"?

Correct answer: B

Rationale: Choice B is the best response as it provides empathy and encourages the client to talk about her experience, which can be therapeutic. This approach validates the client's feelings and offers support. By acknowledging the difficulty and fear experienced by the client, the nurse opens the door for the client to express her emotions and begin the process of coping with the trauma. Choices A, C, and D do not address the emotional impact of the traumatic event or provide an opportunity for the client to express her feelings and concerns. Choice A immediately jumps to medication without exploring other supportive interventions. Choice C focuses on practical solutions without addressing the client's emotional needs. Choice D suggests a drastic solution without considering the client's emotional state or preferences.

4. The licensed practical nurse is observing a graduate nurse as she assesses the central venous pressure. Which observation would indicate that the graduate needs further teaching?

A. The graduate places the client in a supine position to read the manometer.
B. The graduate turns the stop-cock to the off position from the IV fluid to the client.
C. The graduate instructs the client to perform the Valsalva maneuver during the CVP reading.
D. The graduate notes the level at the top of the meniscus.

Correct answer: C

Rationale: The correct answer is C because the client should breathe normally during a central venous pressure monitor reading. Placing the client in a supine position (Choice A) is correct if the client can tolerate it. Turning the stop-cock off (Choice B) and noting the level at the top of the meniscus (Choice D) are also correct actions during CVP monitoring. Instructing the client to perform the Valsalva maneuver is incorrect as it can artificially alter the CVP reading, indicating a need for further teaching.

5. A client reports that he is 'talking to the voices.' The nurse observes this behavior. The nurse's next action should be:

A. touching the client to help him return to reality
B. leaving the client alone until reality returns
C. asking the client to describe what is happening
D. telling the client there are no voices

Correct answer: A

Rationale: When a client reports talking to voices, the nurse should engage in a gentle touch to help the client return to reality. It is important for the nurse to acknowledge the client's experience and attempt to redirect them gently. Touch can provide grounding and connection. Asking the client to describe what is happening can be overwhelming and might exacerbate the situation. Leaving the client alone may not be safe or therapeutic as the client may need support. Telling the client there are no voices denies their reality and is not helpful in managing their experience.