NCLEX-PN
Nclex Exam Cram Practice Questions Questions
Extract:
Question 1 of 5
When evaluating the lab work of a client in hepatic coma, which of the following lab tests is most important?
Correct Answer: C
Rationale: When a client is in hepatic coma due to liver failure, the liver cannot metabolize amino acids completely, leading to elevated ammonia levels. Increased ammonia can cause brain-tissue irritation, worsening the coma.
Therefore, monitoring serum ammonia levels is crucial in assessing the severity of hepatic coma.
Choices A, B, and D are less relevant in the context of hepatic coma. Blood urea nitrogen primarily assesses kidney function, serum calcium levels are not directly related to hepatic coma, and serum creatinine is more indicative of kidney function rather than liver function in this scenario.
Question 2 of 5
A nurse is reviewing the notes written by a nurse on a previous shift. Which note in the client's record reflects the correct use of guidelines for documentation?
Correct Answer: C
Rationale: Quality documentation and reporting require information to be factual, accurate, complete, current, and organized.
Choice C, 'The client's intake was 360 mL,' reflects the correct use of guidelines for documentation as it provides a specific and measurable observation. This note meets the criteria for quality documentation by being specific and quantifiable.
Choices A, B, and D lack specificity and quantifiability.
Choice A includes a subjective term 'well,' choice B uses 'seems' indicating uncertainty, and choice D uses a vague term 'large' without quantifying the amount.
Question 3 of 5
A client who has undergone a total hip replacement is told that she will need to go to an extended care rehabilitation facility for therapy before going home. Which member of the healthcare team should the nurse ask to plan the discharge and transition from the hospital to the rehabilitation facility?
Correct Answer: D
Rationale: In this scenario, the appropriate member of the healthcare team to plan the discharge and transition from the hospital to the rehabilitation facility is the social worker. Social workers are trained to provide counseling services, emotional support, arrange placements in care facilities, and locate financial resources for clients. While clergy provide spiritual support and guidance, physical therapists assist in physical treatments, and occupational therapists help with activities of daily living, the social worker is best suited to address the client's needs related to discharge planning and transition.
Therefore, the correct answer is the social worker.
Question 4 of 5
When providing perineal care to a female client, how should the nurse perform the procedure?
Correct Answer: A
Rationale: When providing perineal care to a female client, the nurse should wear gloves and wash the perineal area from front to back. This technique helps prevent the introduction of E. coli and other bacteria into the urethra, reducing the risk of urinary tract infections. Washing from back to front can introduce bacteria from the anal area to the urethra, leading to infections. Performing the procedure without gloves or having the client perform all care does not adhere to infection control practices. Pouring water from a sterile bottle alone may not ensure proper cleansing and infection prevention.
Therefore, choices B, C, and D are incorrect as they do not follow proper perineal care guidelines.
Question 5 of 5
The nurse and a colleague are on the elevator after their shift, and they hear a group of healthcare providers discussing a recent client scenario. Which client right might be breached?
Correct Answer: C
Rationale: The right to confidentiality of client information might be breached when client care situations are discussed in public areas or without regard to maintaining the information as private and confidential. In this scenario, the conversation on the elevator could lead to a breach of the client's right to confidentiality. The other options, such as the right to refuse treatment, right to continuity of care, and right to reasonable responses to requests, are not being breached in this instance, making them incorrect choices.