NCLEX-PN
Nclex Exam Cram Practice Questions Questions
Extract:
Question 1 of 5
Which of the following is an appropriate nursing goal for a client at risk for nutritional problems?
Correct Answer: B
Rationale: The correct answer is to promote healthy nutritional practices. This goal focuses on preventive measures to address the client's nutritional risk. Providing oxygen (
Choice
A) is not directly related to addressing nutritional problems. Treating complications of malnutrition (
Choice
C) involves addressing the consequences rather than preventing or managing the nutritional problems. Increasing weight (
Choice
D) would only be appropriate if the client is underweight; it does not address the broader aspect of promoting overall healthy nutritional practices.
Question 2 of 5
What should be the first action upon the discovery of an electrical fire?
Correct Answer: A
Rationale: The correct initial action upon discovering an electrical fire is to disconnect the electrical power if it can be done safely. This helps prevent the fire from spreading through the electrical system. Smothering the fire with a blanket is not recommended for electrical fires as it can fuel the fire. Saturating the source with water or other liquids is also not advised as it can lead to electric shock or spread the fire. Activating the fire alarm is important, but it should be done after disconnecting the power to prevent further escalation of the fire.
Question 3 of 5
Which direction given to the nursing assistant is most likely to accomplish the task of getting a urine specimen delivered to the lab immediately after collection?
Correct Answer: D
Rationale: Effective delegation depends on clear, concise direction that leaves no room for question or interpretation on the part of the one being delegated to. In this scenario, the most appropriate direction is to ensure the urine specimen is collected promptly and delivered to the lab immediately.
Choice A is too vague and does not specify the urgency required.
Choice B does not emphasize the immediate need for the specimen to be delivered.
Choice C introduces unnecessary medical information that is beyond the scope of a nursing assistant and may cause confusion.
Therefore, choice D is the correct answer as it provides clear instructions for immediate action without room for misunderstanding.
Question 4 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 5 of 5
A nurse is performing suctioning through an adult client's tracheostomy tube. The nurse notes that the client's oxygen saturation is 89% and terminates the procedure. Which action would the nurse take next?
Correct Answer: D
Rationale: The nurse should monitor the client's heart rate and pulse oximetry during suctioning to assess the client's tolerance of the procedure. Oxygen desaturation to below 90% indicates hypoxemia. If hypoxia occurs during suctioning, the nurse must terminate the procedure and oxygenate the client with 100% oxygen to address the hypoxemia promptly and ensure the client's safety. Rechecking the pulse oximetry reading is important, but the priority is to address the hypoxemia by providing oxygen. Contacting the healthcare provider or respiratory therapist is not necessary at this time as the nurse can manage the hypoxemia with oxygenation. Oxygenating the client with 100% oxygen is the immediate action required in this situation.