while on the wound care team the nurse notices that a fellow nurse opens extra colloid dressing that are often thrown away when they are not needed wh while on the wound care team the nurse notices that a fellow nurse opens extra colloid dressing that are often thrown away when they are not needed wh
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NCLEX NCLEX-PN

Nclex PN Questions and Answers

1. While on the wound care team, the nurse notices that a fellow nurse opens extra colloid dressings that are often thrown away when they are not needed. What should the nurse do?

Correct answer: Discuss with the colleague the concern about wasting supplies.

Rationale: The correct answer is to discuss with the colleague the concern about wasting supplies. By addressing this issue, the nurse can promote cost-effective care within the unit. While it may not directly impact client care, the wastage of supplies affects the unit's supply cost, making choice A incorrect. Choice C is incorrect as it assumes the charge nurse is solely responsible for the ordering process and overlooks the opportunity for direct communication between colleagues. Choice D is incorrect as it involves taking matters into one's own hands rather than addressing the issue through communication and collaboration.

2. After securing the client’s safety from a faulty electric bed, what should the nurse do next?

Correct answer: D: Prepare an incident report.

Rationale: After ensuring the client's safety from the faulty electric bed, the nurse should prioritize preparing an incident report. This report documents the details of what happened and is crucial for quality improvement and risk management. Choice A, discussing the matter with the client's significant others, may be important in some cases but is not the immediate priority after a safety incident. Choice B, documenting the incident in the client's record, is necessary but should be preceded by preparing an incident report. Choice C, notifying the physician, is important but not as urgent as preparing the incident report to ensure timely reporting and investigation of the safety issue.

3. Which information should be reported to the state Board of Nursing?

Correct answer: The narcotic count has been incorrect on the unit for the past 3 days.

Rationale: The correct answer is 'The narcotic count has been incorrect on the unit for the past 3 days.' This information should be reported to the state Board of Nursing as it involves medication errors and potential drug diversion, which are serious issues that fall under the jurisdiction of the Board. Reporting medication discrepancies and errors in narcotic counts is crucial for patient safety and regulatory compliance. Choices A, C, and D involve different types of issues that are not within the direct purview of the Board of Nursing. Providing literature in multiple languages (Choice A), addressing billing practices (Choice C), and resolving staff performance issues (Choice D) should be handled internally or reported to the appropriate departments or authorities, such as the Joint Commission or the charge nurse.

4. A patient has been diagnosed with fibromyalgia and COPD. Which of the following tasks should the nurse delegate to a nursing assistant?

Correct answer: Transferring the patient to the shower.

Rationale: The correct answer is to delegate the task of transferring the patient to the shower to a nursing assistant. Nursing assistants are trained to assist with transfers safely, making this task appropriate for delegation. Ambulating the patient for the first time involves assessing the patient's mobility and tolerance, which requires more assessment and monitoring by a nurse, especially in a patient with fibromyalgia and COPD. Taking the patient's breath sounds involves assessing the patient's respiratory status, which is a nursing responsibility due to the need for clinical judgment. Educating the patient on monitoring fatigue involves providing vital information and should be done by the nurse to ensure comprehensive understanding and tailored recommendations.

5. The nurse is caring for a client recovering from a stroke who recently regained consciousness. The client is having difficulty communicating verbally with the team. Which of the following actions would be least appropriate?

Correct answer: C: Wait for the physician's order for speech therapy before assisting with the appropriate documentation.

Rationale: In this scenario, the least appropriate action would be to wait for the physician's order for speech therapy before assisting with the appropriate documentation. The nurse should start by collecting client data without needing the physician's order, use documents to provide information for the referral, and actively participate in the client referral process. Waiting for the physician's order unnecessarily delays potentially crucial therapy for the client's recovery, affecting the timeliness and effectiveness of care. Therefore, choice C is the least appropriate as immediate action is required in such situations.

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