NCLEX-PN
Nclex PN Questions and Answers Questions
Extract:
Question 1 of 5
A nurse is planning to administer an oral antibiotic to a client with a communicable disease. The client refuses the medication and tells the nurse that the medication causes abdominal cramping. The nurse responds, 'The medication is needed to prevent the spread of infection, and if you don't take it orally I will have to give it to you in an intramuscular injection.' Which statement accurately describes the nurse's response to the client?
Correct Answer: C
Rationale: The correct answer explains the concept of assault, which is an intentional threat to bring about harmful or offensive contact. In the scenario provided, the nurse's statement about administering the medication via an intramuscular injection without the client's consent constitutes a threat, potentially falling under the definition of assault.
Choice A is incorrect because the nurse's action is not automatically justified solely by the client having a communicable disease.
Choice D is also incorrect because even with a prescription, the nurse cannot administer the medication without the client's consent.
Choice C provides a detailed explanation distinguishing assault from battery, which helps in understanding the legal implications of the nurse's response in this situation.
Question 2 of 5
The nurse is caring for a non-English speaking client. The surgeon has asked the nurse to hurry up and prepare the client for their scheduled procedure, which is running late. Which of the following is least appropriate?
Correct Answer: C
Rationale: Allowing the client's family member to serve as the interpreter is the least appropriate option. It is not recommended to rely on family members for interpretation as they may not be impartial, accurate, or trained to handle sensitive medical information. This can lead to misunderstandings, breaches in confidentiality, and compromised care.
Choice A is a better option as it involves communication with the family member to manage expectations.
Choice B is also appropriate as it prioritizes the need for a professional interpreter to ensure accurate communication.
Choice D is a valid option as it explores the possibility of using a phone-service interpreting service to facilitate communication efficiently.
Question 3 of 5
A client scheduled for a left mastectomy and axillary lymph node dissection is wearing a wedding band on her left ring finger. The nurse should take which action?
Correct Answer: C
Rationale: In most situations, a wedding band may be taped in place and worn during a surgical procedure. However, if there is a possibility that the client will experience swelling of the hand or fingers, the wedding band should be removed. On admission to a healthcare facility, the client is usually asked to sign a form that releases the agency from responsibility if a client's valuables are lost. After a mastectomy with axillary lymph node dissection, the client is at risk for lymphedema, which can result in swelling of the arm and hand on the affected side.
Therefore, the appropriate nursing action is to ask the client to remove the wedding band and explain why. This ensures the client's safety and prevents potential complications. Option A is incorrect because taping the wedding band may not be sufficient if swelling occurs. Option B is incorrect as it does not address the immediate need to remove the wedding band. Option D is incorrect because it fails to provide the client with the necessary information about the potential risks of wearing the wedding band during surgery.
Question 4 of 5
When documenting in the client’s record, what type of information should be recorded?
Correct Answer: C
Rationale: When documenting in a client's record, it is crucial to record objective information. Objective information is factual, based on observations and measurable data. This type of information is essential for accurate and effective communication among healthcare professionals involved in the client's care.
Choices A and B, educated predictions of outcomes and personal opinions, are subjective in nature and may not provide an accurate representation of the client's condition.
Choice D, subjective information, includes personal feelings, interpretations, and opinions, which are not ideal for documentation as they can be biased and unreliable.
Question 5 of 5
A 51-year-old client with amyotrophic lateral sclerosis (Lou Gehrig disease) is admitted to the hospital because his condition is deteriorating. The client tells the nurse that he wants a do-not-resuscitate (DNR) order. The nurse should provide the client with which information?
Correct Answer: C
Rationale: When a client requests a DNR order, the nurse should contact the healthcare provider so that the provider may discuss the request with the client. A DNR order should be written, not verbal, following agency and state guidelines.
Therefore, the correct answer is that the DNR request should be discussed with the healthcare provider, who will write the order. Option A is incorrect as oral consent is not sufficient for a DNR order. Option B is incorrect because the client, not the family, has the authority to request a DNR order. Option D is incorrect because the healthcare provider discusses the request with the client but does not make the final decision.