NCLEX-PN
NCLEX PN Test Bank Questions
Extract:
Question 1 of 5
A nurse is preparing to administer medications to a client via a nasogastric (NG) tube. Before administering the medication, the nurse must first take which action?
Correct Answer: C
Rationale: Before administering medications through an NG tube, the nurse must first check the placement of the tube to prevent aspiration. This is done by aspirating gastric contents and measuring the pH. Checking the client's apical pulse is unrelated to NG tube medication administration. Checking when the last feeding was given is important but not a priority before administering medications. Checking when the last medications were given is also not directly related to ensuring the safe administration of medications through an NG tube. Ensuring the correct placement of the tube is crucial to prevent complications such as pulmonary aspiration.
Question 2 of 5
A licensed practical nurse arrives at work at the long-term care center and is immediately faced with several activities that require attention. Which activity will the nurse attend to first?
Correct Answer: A
Rationale: The nurse's priority should be attending to task assignments for the day. This ensures that client care can begin promptly and efficiently. Stocking the medication closet is important but can be done after ensuring task assignments are clear. Phone messages from employee health services and a client's wife, although important, can be addressed after organizing the staff for client care.
Question 3 of 5
A health care provider asks the nurse caring for a client with a new colostomy to request the hospital's stoma nurse to visit the client and assist with colostomy care. The nurse initiates the consultation, understanding that the stoma nurse will be able to influence the client because of which type of power?
Correct Answer: A
Rationale: Power is the ability to influence others to achieve goals. Expert power results from knowledge and skills that one possesses that are needed by others. In this scenario, the stoma nurse's expertise in colostomy care gives them the ability to influence the client effectively. Reward power is based on the ability to grant rewards and favors, which is not applicable in this situation. Coercive power is based on fear and the ability to punish, which is not the case in seeking assistance for colostomy care. Referent power results from followers' desire to identify with a powerful person, which is not the primary influence in this context.
Question 4 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.
Question 5 of 5
How far should the enema tube be inserted for a client to have a flatus-reducing enema?
Correct Answer: A
Rationale: The correct answer is to insert the enema tube 4 inches. Enema tubing must be passed beyond the internal sphincter, which is typically around 4 inches in an adult. Inserting the tube only 2 inches is not far enough to reach this point. On the other hand, inserting the tube 6 or 8 inches is too far and might cause trauma to the bowel, which is unnecessary for a flatus-reducing enema.
Therefore, the correct insertion depth of the enema tube is crucial to ensure effectiveness and safety in providing the intended treatment.