NCLEX-PN
Nclex Exam Cram Practice Questions Questions
Question 1 of 5
In an emergency situation where a client is unconscious and requires immediate surgery, what action is necessary with regard to informed consent?
Correct Answer: A
Rationale: In emergency situations where obtaining consent is not possible due to the client's condition, healthcare providers are allowed to perform life-saving procedures without informed consent. It is assumed that the client would want to receive necessary treatment to save their life. Therefore, the correct action is for the healthcare team to proceed with the surgery as consent is not needed. Waiting to contact the client's family for consent can delay life-saving treatment, risking the client's life. Contacting the hospital clergy for consent is unnecessary and can cause further delays. Obtaining consent from the client's legal guardian is not feasible in this critical situation and may lead to a delay in providing essential care.
Question 2 of 5
A nurse is reviewing the notes written by a nurse on a previous shift. Which note in the client's record reflects the correct use of guidelines for documentation?
Correct Answer: C
Rationale: Quality documentation and reporting require information to be factual, accurate, complete, current, and organized. Choice C, 'The client's intake was 360 mL,' reflects the correct use of guidelines for documentation as it provides a specific and measurable observation. This note meets the criteria for quality documentation by being specific and quantifiable. Choices A, B, and D lack specificity and quantifiability. Choice A includes a subjective term 'well,' choice B uses 'seems' indicating uncertainty, and choice D uses a vague term 'large' without quantifying the amount.
Question 3 of 5
A client whose right leg is in skeletal traction complains of pain in the leg. Which action should the nurse take first?
Correct Answer: C
Rationale: When a client in skeletal traction complains of pain, the priority action for the nurse is to realign the client. Severe pain may indicate the need for realignment or that the traction weights are too heavy. Realigning the client should be the initial response as it can help alleviate the pain by ensuring proper alignment. Asking the client to wiggle their toes may not address the underlying issue causing the pain. Removing traction weights should never be done unless specifically ordered by the healthcare provider as it can affect the traction's effectiveness. Medicating the client with analgesics should only be considered after attempting to address the cause of the pain, which in this case, is realignment.
Question 4 of 5
A nurse is performing suctioning through an adult client's tracheostomy tube. The nurse notes that the client's oxygen saturation is 89% and terminates the procedure. Which action would the nurse take next?
Correct Answer: D
Rationale: The nurse should monitor the client's heart rate and pulse oximetry during suctioning to assess the client's tolerance of the procedure. Oxygen desaturation to below 90% indicates hypoxemia. If hypoxia occurs during suctioning, the nurse must terminate the procedure and oxygenate the client with 100% oxygen to address the hypoxemia promptly and ensure the client's safety. Rechecking the pulse oximetry reading is important, but the priority is to address the hypoxemia by providing oxygen. Contacting the healthcare provider or respiratory therapist is not necessary at this time as the nurse can manage the hypoxemia with oxygenation. Oxygenating the client with 100% oxygen is the immediate action required in this situation.
Question 5 of 5
A client with a closed chest tube drainage system accidentally disconnects the chest tube while being turned by the nurse. What should the nurse do first?
Correct Answer: A
Rationale: When a chest tube becomes disconnected, the priority action is to immediately reattach it to the drainage system or submerge the end in a bottle of sterile water or saline solution to reestablish a water seal. This helps prevent air from entering the pleural space and causing complications. Calling the health care provider is important but not the first action in this emergency. Instructing the client to inhale and hold his breath should be avoided as it can introduce atmospheric air into the pleural space, leading to potential issues. Clamping the chest tube is generally contraindicated, especially in cases of residual air leak or pneumothorax, as it may result in a tension pneumothorax by preventing air from escaping.