NCLEX-PN
Nclex PN Questions and Answers Questions
Extract:
Question 1 of 5
The nurse is caring for a non-English speaking client. The surgeon has asked the nurse to hurry up and prepare the client for their scheduled procedure, which is running late. Which of the following is least appropriate?
Correct Answer: C
Rationale: Allowing the client's family member to serve as the interpreter is the least appropriate option. It is not recommended to rely on family members for interpretation as they may not be impartial, accurate, or trained to handle sensitive medical information. This can lead to misunderstandings, breaches in confidentiality, and compromised care.
Choice A is a better option as it involves communication with the family member to manage expectations.
Choice B is also appropriate as it prioritizes the need for a professional interpreter to ensure accurate communication.
Choice D is a valid option as it explores the possibility of using a phone-service interpreting service to facilitate communication efficiently.
Question 2 of 5
A nursing student is assigned to care for a client who requires a total bed bath. When the student explains to the client that she is going to gather supplies to administer the bath, the client states, 'I don't want a bath. I've been up all night, and I'm clean enough.' The student reports the client's refusal to the nurse. Which action by the nurse is appropriate?
Correct Answer: B
Rationale: The client has the right to refuse a treatment or procedure, and if the client does refuse, the nurse must respect the client's decision.
Therefore, the nurse would allow the client to rest. Persuading the client to have a bath and giving the bath anyway are both inappropriate as they violate the client's rights. Informing the health care provider of the refusal of care can be discussed with the client if needed, but the immediate action should be to respect the client's wishes and allow them to rest.
Question 3 of 5
Which of the following activities is not part of client advocacy?
Correct Answer: C
Rationale: The correct answer is 'sharing your personal opinions to help provide additional information.' Client advocacy involves supporting the client's autonomy and choices. It is essential for the nurse to involve the client in treatment and decision-making (
Choice
A) to ensure their preferences are considered. Standing up for what is right for the client (
Choice
B) is also a crucial aspect of advocacy, ensuring their rights and well-being are protected. Encouraging the client to advocate for themselves (
Choice
D) empowers the client to express their needs. However, sharing personal opinions (
Choice
C) may influence the client's decision-making process and is not a recommended practice in client advocacy, as it can compromise the client's autonomy.
Question 4 of 5
An advance directive is written and notarized according to law in the state of Colorado. This document is legal and binding:
Correct Answer: B
Rationale: The correct answer is 'in the state of Colorado only.' Advance directive protocols and documents are specific to each state's laws and regulations.
Choice A is incorrect as advance directives are not universally recognized internationally.
Choice C is incorrect as the legal validity of an advance directive is limited to the state in which it was created.
Choice D is incorrect as the legal reach of an advance directive typically extends throughout the state of origination, not just the county.
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?
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.