NCLEX-PN
Nclex PN Questions and Answers Questions
Extract:
Question 1 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?
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 2 of 5
Which of the following is true of advanced directives?
Correct Answer: A
Rationale: The correct answer is that advanced directives should be appropriately documented in the client's chart. Advanced directives are legal requests regarding a client's healthcare that come into effect under specific circumstances, regardless of the severity of their illness or level of consciousness.
Choice B is incorrect because advanced directives can cover various healthcare decisions, not just terminal illnesses.
Choice C is incorrect as advanced directives can be established and documented while the client is conscious, not only if they are unconscious.
Choice D is incorrect because advanced directives are indeed legal requests, not non-legal requests.
Question 3 of 5
The nurse manager of a quality improvement program asks a nurse in the neurological unit to conduct a retrospective audit. Which action should the auditing nurse plan to perform in this type of audit?
Correct Answer: D
Rationale: Quality improvement, also known as performance improvement, focuses on processes contributing to client safety and care outcomes. Retrospective audits involve reviewing medical records after discharge for compliance with standards. Concurrent audits assess staff compliance during a client's stay.
Therefore, obtaining the medical record from the hospital's record room for review is crucial in a retrospective audit. Options A, B, and C are more suited for concurrent audits as they involve real-time assessment during a client's stay.
Question 4 of 5
What type of injury is associated with acute hyphema?
Correct Answer: B
Rationale: Acute hyphema is associated with an eye injury, typically resulting from blunt trauma. The presence of blood in the anterior chamber of the eye causes a half-moon appearance or a horizontal line across the globe when the client is upright.
Choices A, C, and D are incorrect because acute hyphema is not related to orthopedic injuries, insect stings, snakebites, or gynecological trauma.
Question 5 of 5
Which of the following scenarios are considered violations of HIPAA laws?
Correct Answer: C
Rationale: Scenarios B and C are considered violations of HIPAA laws. Looking up the medical information of a friend who is not in your care, even with permission, is a violation of HIPAA as the friend is not your patient. Checking on your spouse's medical record, even as a power of attorney, is a violation unless it is directly related to caregiving decisions
Discussing discharge plans with a client in a multi-bed recovery room with the curtain drawn around the client's bed is not a violation of HIPAA. This scenario is considered an 'incidental disclosure' and is not a breach of HIPAA privacy rules. Avoiding conversations about clients while in line in the cafeteria with a mutual caregiver of that client is actually a good practice as it maintains client confidentiality.