NCLEX-PN
NCLEX PN Test Bank
1. Which situation is an example of the use of evidence-based practice in the delivery of client care?
- A. Encouraging a client who has had a stroke to consume thickened liquids and soft foods
- B. Picking up a dislodged radiation implant with long-handled forceps and placing it in a lead container to minimize radiation exposure
- C. Pouring 1 to 2 mL of sterile solution that will be used for wound cleansing into a plastic-lined waste receptacle before pouring the solution into a sterile basin
- D. Blowing on a fingerstick site to dry it after cleaning the site with an alcohol swab
Correct answer: C
Rationale: Evidence-based practice is an approach that integrates client preferences, clinical expertise, and the best research evidence to deliver quality care. Pouring sterile solution into a plastic-lined waste receptacle before using it for wound cleansing reflects evidence-based practice by preventing the entrance of harmful bacteria into the wound. Option A is incorrect because encouraging a stroke client to consume thickened liquids and soft foods is appropriate, not thin liquids and foods that pose a choking risk. Option B is incorrect as picking up a radiation implant with long-handled forceps to minimize radiation exposure is a safety measure, not evidence-based practice. Option D is incorrect because blowing on a fingerstick site after cleaning can recontaminate the site, which goes against best practices in infection control.
2. What is the appropriate intervention for a client who is restrained?
- A. Remove the restraints and provide skin care every hour.
- B. Document the condition of the client's skin every 3 hours.
- C. Assess the restraint every 30 minutes
- D. Tie the restraint to the side rails.
Correct answer: C
Rationale: The correct intervention when a client is restrained is to assess the restraint every 30 minutes. This ensures the safety and well-being of the client by checking for proper fit, circulation, and signs of distress. Removing restraints and providing skin care every hour may not be necessary and could increase the risk of skin breakdown. Documenting the skin condition every 3 hours is important but not the immediate intervention needed when a client is restrained. Tying the restraint to the side rails is unsafe and can cause harm to the client, as restraints should be secured to the bed frame or an immovable part of the bed.
3. Which cultural group has the highest incidence of inflammatory bowel disease (IBD)?
- A. Asians
- B. Caucasians
- C. Hispanics
- D. African Americans
Correct answer: B
Rationale: The correct answer is Caucasians. Studies have shown that Caucasians have the highest incidence of inflammatory bowel disease (IBD) compared to other cultural groups. While IBD can affect individuals from various backgrounds, the prevalence is notably higher in Caucasians. Asians, Hispanics, and African Americans have a lower incidence of IBD compared to Caucasians, making them incorrect choices in this context.
4. What is the 24-hour day-night cycle known as?
- A. circadian rhythm
- B. infradian rhythm
- C. ultradian rhythm
- D. non-REM rhythm
Correct answer: A
Rationale: The correct answer is circadian rhythm. Circadian rhythm refers to the rhythmic repetition of patterns that occur approximately every 24 hours, regulating various biological processes related to the day-night cycle. Infradian rhythm, which is longer than 24 hours, and ultradian rhythm, which is shorter than 24 hours, are not the correct terms for the 24-hour cycle. Non-REM rhythm does not specifically relate to the 24-hour day-night cycle, making it an incorrect choice.
5. What type of injury is associated with acute hyphema?
- A. orthopedic
- B. eye
- C. insect sting or snakebite
- D. gynecological trauma
Correct answer: B
Rationale: Acute hyphema is associated with an eye injury, typically resulting from blunt trauma. The presence of blood in the anterior chamber of the eye causes a half-moon appearance or a horizontal line across the globe when the client is upright. Choices A, C, and D are incorrect because acute hyphema is not related to orthopedic injuries, insect stings, snakebites, or gynecological trauma.
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