NCLEX-PN
2024 Nclex Questions Questions
Question 1 of 5
The mother of a newborn child is very upset. The child has a cleft lip and palate. The type of crisis this mother is experiencing is:
Correct Answer: C
Rationale: The mother is experiencing a situational crisis as the unexpected birth of a child with a cleft lip and palate has placed her in a challenging situation she did not anticipate. This type of crisis is triggered by specific events and circumstances.
Choice A, reactive, implies responding to a stressor after it has occurred, which is not the case here.
Choice B, maturational, refers to stress related to developmental stages, not to external events like the child's condition.
Choice D, adventitious, involves crises resulting from events outside one's control, such as natural disasters, which do not apply in this scenario.
Question 2 of 5
While walking in the hallway of an acute care unit of the hospital, the nurse overhears the change of shift report. What should the nurse do?
Correct Answer: A
Rationale:
To protect the confidentiality of the information being reported, the nurse should make the charge nurse on the unit aware of the situation. This allows the charge nurse to take necessary steps to maintain confidentiality and ensure that the information is communicated in an appropriate and private manner. Disclosing the situation to the charge nurse is essential to address any breaches in confidentiality and uphold professional standards of privacy and ethics. Disregarding the information, returning to their own unit without disclosure, or ignoring the situation altogether would not address the breach of confidentiality and could lead to further issues regarding patient privacy and trust.
Question 3 of 5
An elderly client is diagnosed with ovarian cancer. She has surgery followed by chemotherapy with fluorouracil (Adrucil) IV. What should the nurse do if she notices crystals and cloudiness in the IV medication?
Correct Answer: A
Rationale: Crystals in the solution are not normal and should not be administered to the client. Discarding the solution and ordering a new bag is the correct action to ensure the client's safety. Warming the solution, as suggested in answer B, will not resolve the issue of crystals and cloudiness, which could potentially harm the client. Continuing the infusion, as in answer C, could pose a risk to the client due to the presence of abnormal substances. Answer D, discontinuing the medication, would typically require a doctor's order and should be done after discarding the contaminated solution.
Question 4 of 5
Which of the following statements by a client with spinal cord injury indicates a need for further teaching by the nurse regarding bowel management?
Correct Answer: B
Rationale: The corrected statement indicates the need for further teaching because it suggests consuming fluids like fruit juices, which can include caffeinated options that may stimulate fluid loss through increased urination. It is more appropriate to emphasize the consumption of fluids like water and non-caffeinated fruit juices for proper hydration.
Choices A, C, and D demonstrate a correct understanding of bowel management by focusing on dietary considerations, establishing a regular bowel movement schedule, and using proper positioning during bowel movements. Option B is incorrect as it may lead to increased fluid loss due to caffeine content in some fruit juices.
Question 5 of 5
A 50-milliliter (ml) bolus of normal saline fluid is ordered by the physician. The physician wants it to infuse in 30 minutes. The nurse should set the pump rate at:
Correct Answer: A
Rationale:
To infuse a 50 ml bolus in 30 minutes, the rate should be calculated as follows: 50 ml / 30 min = 100 ml per hour.
Therefore, the correct answer is to set the pump rate at 100 ml per hour for one hour.
Choice A is the correct rate based on the calculation.
Choices B, C, and D all provide incorrect rates that do not match the physician's order.
Choice B would only deliver 30 ml in 30 minutes, not the ordered 50 ml.
Choice C would deliver 120 ml in one hour, which is 20 ml more than ordered.
Choice D would only provide 25 ml over 30 minutes, not the full 50 ml prescribed.