Nclex PN Questions and Answers

Extract:

Question 1 of 5

A nurse on the night shift is making client rounds. When the nurse checks a client who is 97 years old and has successfully been treated for heart failure, he notes that the client is not breathing. If the client does not have a do-not-resuscitate (DNR) order, the nurse should take which action?

Correct Answer: A

Rationale: Administering cardiopulmonary resuscitation (CPR) is the appropriate action when a client is not breathing and does not have a do-not-resuscitate (DNR) order. CPR is considered an emergency treatment that can be provided without client consent in life-threatening situations. Calling the health care provider or nursing supervisor for directions, as well as administering oxygen without addressing the lack of breathing, would delay critical life-saving interventions.
Therefore, administering CPR is the most urgent and necessary action to perform in this scenario.

Question 2 of 5

The nurse is caring for a client recovering from a stroke who recently regained consciousness. The client is having difficulty communicating verbally with the team. Which of the following actions would be least appropriate?

A. Begin client data collection before receiving the physician's order for the referral. B. Use documents to provide information for the referral. C. Wait for the physician's order for speech therapy before assisting with the appropriate documentation. D. Participate in the client referral process.

Correct Answer: C

Rationale: In this scenario, the least appropriate action would be to wait for the physician's order for speech therapy before assisting with the appropriate documentation. The nurse should start by collecting client data without needing the physician's order, use documents to provide information for the referral, and actively participate in the client referral process. Waiting for the physician's order unnecessarily delays potentially crucial therapy for the client's recovery, affecting the timeliness and effectiveness of care.
Therefore, choice C is the least appropriate as immediate action is required in such situations.

Question 3 of 5

The nurse in the emergency room is admitting a client who has sustained a gunshot wound and will require immediate surgery. The client is unconscious and by themselves. Which of the following actions is most appropriate?

A. Call the charge nurse and request that the facility's legal counsel provide a waiver for informed consent. B. Attempt to stabilize the client in the emergency room until they are conscious enough to provide informed consent. C. Try to locate the client's family to obtain informed consent before transporting the client to the operating room. D. Proceed with transporting the client to the operating room without obtaining informed consent.

Correct Answer: D

Rationale: In emergency situations where a client is unconscious and requires immediate surgery to save their life, the priority is to proceed with necessary interventions without delay to ensure the best possible outcome. Obtaining informed consent is essential in healthcare, but in situations where a delay in treatment can be life-threatening, healthcare providers are ethically and legally permitted to proceed with treatment without consent. Attempting to stabilize the client until conscious enough to provide consent or trying to locate family members for consent would cause a dangerous delay in critical care.
Therefore, the most appropriate action in this scenario is to transport the unconscious client to the operating room for immediate surgery.

Question 4 of 5

While on the wound care team, the nurse notices that a fellow nurse opens extra colloid dressings that are often thrown away when they are not needed. What should the nurse do?

A. Do nothing, as it is not impacting client care. B. Discuss with the colleague the concern about wasting supplies. C. Tell the charge nurse to stop ordering these dressings. D. Remove the colloid dressings from the shelf so that the nurse will find other supplies to use.

Correct Answer: B

Rationale: The correct answer is to discuss with the colleague the concern about wasting supplies. By addressing this issue, the nurse can promote cost-effective care within the unit. While it may not directly impact client care, the wastage of supplies affects the unit's supply cost, making choice A incorrect.
Choice C is incorrect as it assumes the charge nurse is solely responsible for the ordering process and overlooks the opportunity for direct communication between colleagues.
Choice D is incorrect as it involves taking matters into one's own hands rather than addressing the issue through communication and collaboration.

Question 5 of 5

A nurse and a nursing assistant enter a client's room to provide care and find the client lying on the floor. Which action should the nurse take first?

A. Ask the nursing assistant to complete an incident report B. Check the client's level of consciousness and vital signs C. Contact the unit secretary on the intercom and ask that the client's health care provider be called D. Ask the nursing assistant to assist in getting the client back to bed

Correct Answer: B

Rationale: When a client sustains a fall, the nurse must first assess the client. The nurse should check the client's level of consciousness and vital signs to determine the severity of the situation and provide appropriate care promptly. This immediate assessment is crucial in ensuring the client's immediate needs are addressed. Asking the nursing assistant to complete an incident report (choice
A) is not the priority as the client's condition needs immediate attention. Contacting the unit secretary to call the client's health care provider (choice
C) can be done after the initial assessment has been completed. Asking the nursing assistant to assist in getting the client back to bed (choice
D) should only be considered after ensuring the client is stable and safe to move.

Nclex PN Questions and Answers - Nurselytic

Nurselytic

NCLEX-PN

NCLEX-PN