NCLEX-PN
NCLEX PN Test Bank Questions
Extract:
Question 1 of 5
A client has signed the informed consent for mastectomy of the left breast. On the morning of the surgical procedure, the client asks the nurse several questions about the procedure that make it obvious that she does not have an adequate comprehension of the procedure. What is the most appropriate response by the nurse?
Correct Answer: B
Rationale: Informed consent is the authorization by a client or a client's legal representative to do something to the client. The surgeon is primarily responsible for explaining the surgical procedure and obtaining informed consent. If the client asks questions that alert the nurse to an inadequacy of comprehension on the client's part, the nurse has the obligation to contact the surgeon.
Choice A is incorrect as the client should be allowed to ask questions even after signing the consent for surgery.
Choice C is not the most appropriate response, as the primary concern is to address the client's lack of comprehension.
Choice D is inaccurate, as while it is the surgeon's responsibility to explain the procedure, in this scenario, the nurse should take immediate action to ensure the client's understanding. Requesting the surgeon to visit and answer the client's questions is the most appropriate response in this situation, as it directly addresses the client's concerns and ensures proper informed consent is obtained.
Question 2 of 5
A nurse is assisting a new nursing graduate with organizational skills in delivering client care. The nurse determines that the new nursing graduate needs assistance with time management if the new graduate takes which action?
Correct Answer: A
Rationale: The correct answer is 'Gathers supplies before beginning a task.' This action indicates a lack of effective time management because gathering supplies before starting a task can lead to inefficiency and time wastage. Effective time management involves organizing tasks efficiently, which includes having all necessary supplies ready before initiating a task. Allowing time for unexpected tasks, prioritizing client needs and daily tasks, and documenting task completion and client information at the end of the day are all essential components of good time management practices.
Therefore, the new nursing graduate should focus on improving the timing of supply gathering to enhance time management skills. The other choices are not indicative of poor time management; instead, they demonstrate important aspects of effective time management in client care delivery.
Question 3 of 5
In which situation is the nurse upholding the ethical principle of fidelity?
Correct Answer: D
Rationale: Fidelity is the ethical principle of keeping promises made to clients, families, and other healthcare professionals. Contacting the health care provider about the client's request to incorporate complementary therapies for pain into the treatment plan exemplifies fidelity. By advocating for the client's preferences and ensuring their requests are addressed, the nurse demonstrates a commitment to fulfilling promises made to the client. Allowing a client to decide when to receive daily hygiene care relates to respecting autonomy, not fidelity. Inserting a 19-gauge intravenous catheter into a client needing a blood transfusion aligns with beneficence, as it involves taking action to provide necessary treatment. Providing complete information to a client with newly diagnosed cancer about treatment options reflects justice, promoting fairness and equity in healthcare by offering equal access to information and treatment choices.
Question 4 of 5
While receiving an infusion of cefazolin sodium, the client complained of itchy skin. The nurse observed warm, flushed skin with a red rash on the arms, chest, and back. The health care provider was promptly notified.
Correct Answer: D
Rationale: Accurate and objective documentation is essential during an incident report.
Choice A makes an assumption of allergy based on subjective interpretation, which is not appropriate.
Choice B states a conclusion without proper documentation.
Choice C is incomplete as it fails to provide a detailed account of the observed symptoms.
Choice D offers a precise description of the client's symptoms, actions taken, and notification of the healthcare provider, making it the most suitable documentation choice.
Question 5 of 5
A nurse sees another nurse changing an intravenous (IV) solution because the wrong solution is infusing into the client. The nurse who changed the IV solution does not report the error. What should the nurse who observed the error do first?
Correct Answer: D
Rationale: The first thing the nurse who observed the error should do is ask the nurse whether she intends to report the error. Ensuring client safety is paramount, and all errors must be reported to the health care provider, but this is not the initial action. The client should also be assessed immediately. The nurse who discovered the error should complete an incident report and make appropriate documentation in the client's record. If the nurse who observed the error finds out that it will not be reported, it may be necessary to involve the supervisor.
Therefore, the best course of action initially is to communicate with the nurse who made the error to understand her intentions regarding reporting.