NCLEX-PN
NCLEX PN Test Bank Questions
Extract:
Question 1 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 2 of 5
Nail and foot care are essential in meeting the basic hygiene needs of clients. Important assessments by the nurse in this area include:
Correct Answer: C
Rationale: The correct answer is to assess the nail beds and the tissue surrounding the nails. This assessment is crucial to identify abnormal discoloration, lesions, paronychia, dryness, breaks in the skin, pressure areas, or any other unusual appearances.
Choice A is incorrect as a full-body assessment is broader and not specific to nail and foot care.
Choice B is incorrect as lab work is not directly related to nail and foot assessments.
Choice D is incorrect as it focuses only on foot corns and calluses, neglecting other important aspects of nail and foot care.
Question 3 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 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
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.