NCLEX-PN
2024 Nclex Questions Questions
Extract:
Question 1 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.
Question 2 of 5
A complication of total parenteral nutrition (TPN) is the development of cholestasis. What is this condition?
Correct Answer: B
Rationale: Cholestasis due to TPN administration is an intrahepatic process that interrupts the normal flow of bile. It is characterized by a reduction or stoppage of bile flow.
Choice A, an inflammatory process of the extrahepatic bile ducts, refers to cholangitis, not cholestasis.
Choice C, an inflammation of the gallbladder, describes cholecystitis, a different condition.
Choice D, the formation of gallstones, is not correct as cholestasis is about the flow of bile, not the formation of gallstones.
Question 3 of 5
As a type of quality indicator, an example of a structure standard is:
Correct Answer: A
Rationale: The correct answer is 'a written philosophy.' Structure standards define the conditions needed to operate a system and do not directly involve client care. Examples include philosophy, objectives, goals, hours of operation, and management responsibility.
Choices B, C, and D involve specific procedures and protocols related to client care, which are not structure standards.
Question 4 of 5
A man expresses surprise that his wife has become very withdrawn during hospitalization for pneumonia. Which response helps the husband understand how some people cope with hospitalization?
Correct Answer: A
Rationale: The correct response acknowledges that hospitalization can lead to a crisis for both patients and their families. By asking if the wife has coped with problems before, it opens up a dialogue about her coping mechanisms and past experiences. This can help the husband understand his wife's current behavior better and provide valuable insights.
Choices B, C, and D do not directly address the potential crisis that hospitalization can cause or inquire about the wife's coping strategies, making them less effective responses.
Question 5 of 5
A client reports that someone is in the room and trying to kill him. The nurse's best response is:
Correct Answer: B
Rationale: When a client reports hallucinations or delusions, it is crucial to respond in a non-confrontational and empathetic manner.
Choice B acknowledges the client's fear without confirming the delusion, showing understanding, and providing reassurance. This response validates the client's feelings without reinforcing the false belief. The other responses in choices A, C, and D dismiss the client's feelings or perceptions, which can escalate the situation and harm the therapeutic relationship.