NCLEX-PN
Nclex Exam Cram Practice Questions
1. What does it mean to be a nursing advocate?
- A. makes decisions for others.
- B. encourages persons to make decisions for themselves and acts with or on behalf of the person to support those decisions.
- C. manages the care of others.
- D. is the legal representative for a person.
Correct answer: B
Rationale: A nursing advocate does not make decisions for others but instead empowers individuals to make decisions for themselves. By encouraging individuals to make their own decisions and supporting them in this process, nursing advocates uphold the principle of self-determination. This approach respects the autonomy and independence of individuals in managing their care. Therefore, the correct answer is to 'encourage persons to make decisions for themselves and act with or on behalf of the person to support those decisions.' Choices A, C, and D are incorrect as they do not align with the role of a nursing advocate in promoting patient autonomy and self-determination.
2. Which of the following foods should be avoided by clients who are prone to developing heartburn as a result of gastroesophageal reflux disease (GERD)?
- A. lettuce
- B. eggs
- C. chocolate
- D. butterscotch
Correct answer: C
Rationale: The correct answer is chocolate. Ingestion of chocolate can reduce lower esophageal sphincter (LES) pressure, leading to reflux and clinical symptoms of GERD. Lettuce and eggs do not significantly affect LES pressure, making them less likely to trigger GERD symptoms. Butterscotch, like lettuce and eggs, does not have a notable effect on LES pressure, so it is not as likely to worsen GERD symptoms as chocolate. Therefore, chocolate is the food to be avoided by clients prone to heartburn due to GERD.
3. 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?
- A. Rechecking the pulse oximetry reading
- B. Calling the respiratory therapist
- C. Calling the healthcare provider
- D. Oxygenating the client with 100% oxygen
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.
4. All of the following tasks could be delegated to a nursing assistant or unlicensed assistive personnel (UAP) except:
- A. monitoring intravenous infusion
- B. assisting a client to the bathroom
- C. offering fluid intake every 1-2 hours
- D. monitoring/recording the amount of fluid taken
Correct answer: A
Rationale: Monitoring an intravenous infusion involves assessing for complications, adjusting the flow rate, and monitoring the client's response, which requires the knowledge and skills of a licensed nurse (RN or LPN). Tasks that can be delegated to nursing assistants or unlicensed assistive personnel include assisting a client to the bathroom, offering fluids, and recording fluid intake. These activities are within the scope of practice for UAPs as they do not involve the specialized knowledge and training needed for intravenous infusion monitoring.
5. A risk management program within a hospital is responsible for all of the following except:
- A. identifying risks.
- B. controlling financial loss due to malpractice claims.
- C. ensuring that staff follow their job descriptions.
- D. analyzing risks and trends to guide further interventions or programs.
Correct answer: C
Rationale: A risk management program within a hospital is responsible for identifying risks, controlling financial loss due to malpractice claims, and analyzing risks and trends to guide further interventions or programs. It is not responsible for ensuring that staff follow their job descriptions. Monitoring staff adherence to their job descriptions falls under the purview of departmental managers or supervisors. The primary focus of a risk management program is to assess, mitigate, and manage risks related to patient safety, quality of care, and financial implications, rather than overseeing staff job descriptions.
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