NCLEX-PN
NCLEX PN Test Bank Questions
Extract:
Question 1 of 5
A client with a left arm fracture complains of severe diffuse pain that is unrelieved by pain medication. On further assessment, the nurse notes that the client experiences increased pain during passive motion compared with active motion of the left arm. Based on these assessment findings, which action should the nurse take first?
Correct Answer: A
Rationale: The correct answer is to contact the health care provider. The client with early acute compartment syndrome typically complains of severe diffuse pain that is unrelieved by pain medication. Additionally, the affected client experiences greater pain during passive motion compared to active motion. In this situation, it is crucial to notify the health care provider immediately for further evaluation and intervention. Contacting the health care provider is essential to ensure timely diagnosis and appropriate management of the condition. Checking for more pain medication, encouraging active range of motion exercises, or repositioning the client may not address the underlying issue of acute compartment syndrome and could delay necessary interventions.
Therefore, the priority action should be to involve the healthcare provider for prompt assessment and treatment.
Question 2 of 5
A graduate nurse hired to work in a medical unit of a hospital is attending an orientation session. The nurse educator, discussing care maps, asks the graduate nurse whether she understands how a care map is used. Which response indicates understanding?
Correct Answer: A
Rationale: The correct answer is A. A care map, also known as a critical pathway, outlines the day-to-day expected outcomes of care and the outcomes anticipated at discharge or the end of a treatment phase. It includes clinical assessments, treatments, dietary interventions, activity therapies, client education, and discharge planning. While it may identify nursing diagnoses, a care map is developed by all disciplines caring for the client type and is used by the interdisciplinary team, not just the nurse alone.
Choice B is incorrect because a care map is not solely for the nurse but for the entire interdisciplinary team.
Choice C is incorrect as care maps are individualized plans developed by the interdisciplinary team, not just by a nurse.
Choice D is incorrect as a care map is not solely about nursing diagnoses but encompasses a comprehensive plan of care.
Question 3 of 5
A client admitted to the hospital has a do-not-resuscitate (DNR) order in his medical record. The nurse understands which information about DNR orders?
Correct Answer: D
Rationale: The correct answer is that the DNR order requires frequent review as specified by state or agency policy. If the client's condition changes, the DNR order may need to be changed. For this reason, DNR orders require frequent review as specified by state or agency policy. A DNR order may be changed at any time and does not remain in effect for the duration of the client's hospitalization. The client's request regarding DNR status is the priority.
Choice A is incorrect because healthcare providers, not just immediate family members, may change the DNR order based on the client's condition.
Choice B is incorrect as DNR orders can be changed if the client's condition warrants it, not remaining unchanged.
Choice C is incorrect as DNR orders are not fixed for the duration of hospitalization, they can be modified based on the client's needs.
Question 4 of 5
When assessing a client with terminal cancer receiving a continuous intravenous infusion of morphine sulfate, what should the nurse check first?
Correct Answer: B
Rationale: When assessing a client with terminal cancer receiving morphine sulfate via continuous intravenous infusion, the nurse's priority should be checking the client's respiratory status first. Morphine sulfate can lead to respiratory depression, emphasizing the need for close monitoring of breathing. While temperature, pulse, and urine output are all essential components of the assessment, ensuring adequate respiratory function takes precedence due to the potential risk of respiratory depression associated with morphine sulfate. Promptly assessing respiratory status enables early identification of any signs of respiratory distress or depression, allowing for immediate intervention if needed.
Question 5 of 5
When ambulating a client with right-sided weakness, a nursing assistant should be positioned on which side of the client?
Correct Answer: C
Rationale: When ambulating a client with right-sided weakness, the nursing assistant should stand on the affected side, which in this case is the client's right side. This position allows the assistant to provide proper support and assistance. Standing behind the client (
Choice
A) is incorrect as the assistant should be on the affected side. Positioning the free hand on the client's shoulder (
Choice
B) is a correct action as it helps in pulling the client toward them in case of a forward fall. Grasping the security belt in the midspine area of the small of the client's back (
Choice
D) is also correct to provide support and stability during ambulation.