NCLEX-PN
Nclex PN Questions and Answers Questions
Extract:
Question 1 of 5
An example of a process standard on a med-surg unit is:
Correct Answer: D
Rationale: Process standards define the actions and behaviors required by staff to provide care on a med-surg unit. A procedure for changing IV tubing is a critical psychomotor skill necessary for safe and effective patient care in this setting.
Choice B, a policy for staffing, pertains more to organizational management rather than specific care processes on the unit.
Choice C, the job description of the CEO, delineates the responsibilities of the organization's top executive and is not a process standard for frontline staff.
Choice D, a procedure for checking waveforms on a client with an intra-aortic balloon pump, is more specific to a cardiac care unit and not typically performed on a med-surg unit.
Question 2 of 5
A nurse discovers that another nurse has administered an enema to a client even though the client told the nurse that he did not want one. Which is the most appropriate action for the nurse to take?
Correct Answer: A
Rationale: Battery is any intentional touching of a client without the client's consent, which violates the client's rights. If a nurse discovers such an incident, they should report it to the nursing supervisor. Confronting the nurse and threatening charges of battery could lead to unnecessary conflict. Telling the client that the nurse did the right thing is incorrect as it goes against the client's wishes. While the health care provider may need to be notified eventually, the first step should be reporting the incident to the nursing supervisor to address the violation appropriately.
Question 3 of 5
The nurse is working the same shift two days in a row. On the first of these days, while caring for one assigned client, the client says, "Will you promise me you will be my nurse tomorrow?"? Which response is most appropriate?
Correct Answer: D
Rationale: The most appropriate response is to maintain confidentiality regarding work assignments. It is crucial to uphold patient privacy and not disclose information about staff schedules or assignments.
Choices A, B, and C involve promising or redirecting the patient, which is not suitable in this situation.
Choice D respects confidentiality and is the most professional response in this scenario.
Question 4 of 5
While preparing a client for a bronchoscopy, a nurse notes that the client is wearing a gold necklace. What should the nurse do to safeguard the client's necklace?
Correct Answer: A
Rationale: When a client has valuables such as jewelry, the nurse should ensure their safekeeping. It is appropriate for the nurse to ask the client for permission to lock the necklace in the hospital safe to prevent loss or damage. This option prioritizes the security of the necklace while allowing the client to make an informed decision. Asking the client to sign a release form does not guarantee the necklace's safety; it only releases the hospital from liability. Placing the necklace in a bedside table drawer does not provide adequate security as it is not as secure as a hospital safe. Inquiring whether the necklace is gold is irrelevant to safeguarding the jewelry during the procedure, as the primary concern is its safekeeping.
Question 5 of 5
During a hospital program about in vitro fertilization, a television crew arrives to film for a series on hospital services. What action should the nurse conducting the program take?
Correct Answer: C
Rationale: Privacy is a client's right to be free from unwanted intrusion into their private affairs. Videotaping constitutes an invasion of a client's privacy, and written permission is required from the client for actions such as photographing or videotaping.
Therefore, the nurse must explain to the television crew that videotaping is not allowed to protect the attendees' privacy. Option A is incorrect as it still involves recording the individuals, breaching their privacy. Option B is incorrect because allowing videotaping without consent violates privacy rights. Option D is incorrect as it disregards the need for consent and privacy protection.