NCLEX-PN
Nclex PN Questions and Answers Questions
Extract:
Question 1 of 5
The nurse receives an assignment of three clients. Which of the following should the nurse consider as the highest priority when determining which client to assess first?
Correct Answer: D
Rationale: The nurse should prioritize assessing a client with a potential airway obstruction first based on the ABCs (airway, breathing, circulation) principle. Maintaining a clear airway is crucial for oxygenation and ventilation, making it the highest priority.
Choices A and B focus on call bells and waiting times, which are important but not life-threatening in comparison to airway concerns. While pain management is essential, it takes precedence after addressing immediate life-threatening issues like airway compromise.
Question 2 of 5
The nurse is caring for a client awaiting test results on a biopsy. The client is unconscious, and the physician informs the client's spouse that the biopsy came back positive for cancer. The spouse asks the nurse if they will not share this news with the client because they would prefer the client be unaware of the diagnosis. Which of the following responses is most appropriate?
Correct Answer: B
Rationale: The correct response is, "For ethical reasons, I am unable to withhold this information from the client."? The ethical principle of veracity requires that the nurse is truthful with the client and does not withhold information even if it is requested by the family.
Choice A is incorrect because seeking a psychiatrist's confirmation is not necessary to uphold the ethical principle of truth-telling.
Choice C is incorrect as implying that signing paperwork overrides the nurse's ethical obligation to be honest with the client is inappropriate.
Choice D is also incorrect as a durable power of attorney is not relevant in this situation where the spouse is asking the nurse to withhold information.
Question 3 of 5
The nurse in the emergency room is admitting a client who has sustained a gunshot wound and will require immediate surgery. The client is unconscious and by themselves. Which of the following actions is most appropriate?
Correct Answer: D
Rationale: In emergency situations where a client is unconscious and requires immediate surgery to save their life, the priority is to proceed with necessary interventions without delay to ensure the best possible outcome. Obtaining informed consent is essential in healthcare, but in situations where a delay in treatment can be life-threatening, healthcare providers are ethically and legally permitted to proceed with treatment without consent. Attempting to stabilize the client until conscious enough to provide consent or trying to locate family members for consent would cause a dangerous delay in critical care.
Therefore, the most appropriate action in this scenario is to transport the unconscious client to the operating room for immediate surgery.
Question 4 of 5
The LPN notices a client with poor gait and balance. She is currently being treated for hypertension, but the nurse is concerned. What should the nurse do?
Correct Answer: D
Rationale: Nurses should address any concerns regarding a client's health, even if they are not directly related to the reason for hospitalization. In this case, the nurse noticing the client's poor gait and balance should communicate these concerns to the attending physician. The correct course of action is to request a referral to physical therapy, as this specialized intervention can help address the client's issues effectively. Adding gait/balance training to the care plan without professional assessment and intervention may not be appropriate. Doing nothing is not in line with providing comprehensive care, and referring the client to the hospital gym is not as effective as a referral to physical therapy for addressing gait and balance issues.
Question 5 of 5
The client is going for surgery and mentions their religious objection to blood transfusions. Which of the following responses would be most appropriate?
Correct Answer: B
Rationale: The most appropriate response is, '"I understand, and you have the right to refuse blood transfusions."? This answer shows respect for the client's autonomy and religious beliefs. It is crucial for healthcare providers to acknowledge and support a patient's decision-making regarding their care, even if it conflicts with medical advice. Option A is not ideal as it might seem dismissive of the client's beliefs. Option C introduces a potential negative outcome of refusing a blood transfusion, which could induce fear or coercion. Option D is inappropriate because it implies judgment and does not uphold the client's autonomy.