NCLEX-PN
Nclex PN Questions and Answers Questions
Extract:
Question 1 of 5
The client is unsure about making medical decisions as their disease progresses and wants to appoint someone to make these decisions. Which of the following options would be most appropriate?
Correct Answer: C
Rationale: The correct answer is 'a healthcare proxy.' A healthcare proxy involves the client appointing an individual to make medical decisions on their behalf if they become unable to do so. This option allows the client to choose someone they trust to act in their best interests.
Choice A, 'a living will,' is a legal document that outlines a person's wishes regarding medical treatment in case they are unable to communicate their decisions. While it is important, it does not involve appointing someone to make decisions.
Choice B, 'informed consent,' is a process where a healthcare provider explains a treatment or procedure, including its risks and benefits, to a patient who can then decide whether to proceed. This is not about appointing someone to make decisions on the patient's behalf.
Choice D, 'non-informed consent,' is not a valid concept in healthcare. Informed consent is crucial for respecting a patient's autonomy and decision-making capacity.
Question 2 of 5
A nurse is taking a morning break with the unit secretary in the nurses' lounge. The unit secretary says to the nurse, 'I read in Mr. Gage's medical record that he has gonorrhea.' How should the nurse respond to the secretary?
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.
Question 3 of 5
While taking care of a client, the nurse thinks that physical therapy in the hospital might be beneficial to their condition. The following is the ideal referral process EXCEPT?
Correct Answer: D
Rationale: The ideal referral process for a client to receive physical therapy in the hospital starts with the nurse contacting the client's primary care provider to discuss and suggest a physical therapy referral. The primary care provider should provide an official referral, which is crucial for initiating the treatment process. After obtaining the official referral, the nurse should provide the physical therapist with the client's medical record. This step is essential for the therapist to assess the client's condition and customize the treatment plan accordingly. Once the physical therapist is informed and prepared, the nurse can then transport the client to the physical therapy room for treatment.
Therefore, the correct sequence is to first contact the primary care provider (
Choice
C), then provide the medical record (
Choice
B), and finally transport the client for treatment (
Choice
A).
Choice D, suggesting the client self-refer to the physical therapist, is incorrect as the referral process should involve healthcare professionals to ensure proper assessment and treatment planning.
Question 4 of 5
A nurse monitoring a client with a chest tube notes that there is no tidaling of fluid in the water seal chamber. After further assessment, the nurse suspects that the client's lung has reexpanded and notifies the healthcare provider. The healthcare provider verifies with the use of a chest x-ray that the lung has reexpanded, then calls the nurse to ask that the chest tube be removed. Which action should the nurse take first?
Correct Answer: C
Rationale: The correct action for the nurse to take first is to inform the healthcare provider that removal of a chest tube is not a nursing procedure. Actual removal of a chest tube is the duty of a healthcare provider. If the healthcare provider insists that the nurse remove the tube, the nurse must contact the nursing supervisor. Some agencies' policies and procedures may permit an advanced practice nurse to remove a chest tube, but there is no information in the question to indicate that the nurse is an advanced practice nurse.
Choice A is incorrect because the nurse should not proceed with removing the chest tube without proper authorization.
Choice B is incorrect as calling the nursing supervisor should come after clarifying with the healthcare provider.
Choice D is incorrect as the nurse should not begin the process of removing the chest tube without proper guidance and authorization.
Question 5 of 5
Which statement about clinical pathways is inaccurate?
Correct Answer: A
Rationale: The correct answer is that clinical pathways do not necessarily require daily updates. Clinical pathways can be customized to be updated daily, weekly, or at other intervals based on patient needs and facility protocols.
Choice A is inaccurate as daily updates are not always mandatory for clinical pathways.
Choices B, C, and D are accurate features of clinical pathways: they depict the expected client response to the diagnosis, aim for improvement or discharge, and are grounded in evidence-based practices to ensure optimal care.