Nclex PN Questions and Answers - Nurselytic

Correct Answer: B

Rationale: The correct order for the LPN to see the clients is C, B, D, A. It is crucial to prioritize client care based on the urgency of their conditions. The 53-year-old client with lower leg swelling complaining of sudden onset headache and blurry vision (Client
C) should be seen first as they are at the highest risk for serious healthcare complications. Next, the LPN should attend to the 23-year-old client with a left arm fracture after an MVA complaining of significant pain in his arm (Client
B). Following that, the LPN can address the 47-year-old client requesting more information regarding her surgery scheduled in three hours (Client
D). Lastly, the LPN should attend to the 72-year-old client with pneumonia asking to order her dinner (Client
A). This order ensures that the most critical needs are met first, followed by the less urgent ones.
Choice A is incorrect as it places the 72-year-old client before the 23-year-old client with a painful arm.
Choice B is incorrect as it prioritizes the 53-year-old client last.
Choice D is incorrect as it does not address the urgency of the clients' conditions appropriately.

Correct Answer: C

Rationale: A client's medical condition is confidential and should never be discussed with anyone other than the client and the client's healthcare provider.
Therefore, the nurse must tell the unit secretary that the client's condition is not to be discussed.

Choices A and B confirm the client's disease, which is inappropriate as it breaches patient confidentiality.
Choice D promotes further discussion of the client's condition, which is also inappropriate. The correct response is to firmly state, 'We can't discuss a client's medical condition,' to uphold patient privacy and confidentiality.

Correct Answer: C

Rationale: The correct answer is 'The nurse reports in the hallway, in SBAR format, and alerts the oncoming LPN about how rude the client was throughout the shift.' This choice is inappropriate because shift report should be given at the bedside, in SBAR format, and in an objective way. It is important to maintain professionalism and focus on the client's condition and care needs, rather than personal opinions or subjective comments. Reporting in the hallway may compromise patient privacy and confidentiality.

Choices A, B, and D demonstrate appropriate ways of giving shift report by focusing on relevant information, using SBAR format, and discussing client concerns after reviewing the chart, which promotes effective communication and continuity of care.

Correct Answer: A

Rationale: The four categories related to client care plans are diagnosis, intervention, outcome, and evaluation. Privacy is not typically considered a distinct category in client care plans, as it is more of a fundamental aspect that underlies all care provided to clients.

Choices B, C, and D are directly related to the components of client care plans, making them incorrect answers in this context.

Correct Answer: A

Rationale: When a staff member reports to work showing signs of alcohol intoxication, the nurse should objectively note the symptoms and ask a second person to confirm these observations. It is crucial to contact the nursing supervisor immediately. An odor of alcohol, slurred speech, unsteady gait, and errors in judgment are indicators of intoxication, posing a risk to client safety. The staff member should be removed from the client care area. Detailed documentation of the incident is essential, including observations, actions taken, future plans, and the staff member's signature and date on the recorded incident memo. If the staff member refuses to sign, this should be noted by the nurse and a witness. Asking the staff member to rest in the nurses' lounge or restricting medication administration does not ensure client safety, as the staff member could still jeopardize it. Inquiring about the amount of alcohol consumed is confrontational and not relevant to the immediate need of ensuring safety.