NCLEX-PN
NCLEX PN Test Bank
1. How far should the enema tube be inserted for a client to have a flatus-reducing enema?
- A. 4 inches.
- B. 6 inches.
- C. 2 inches.
- D. 8 inches.
Correct answer: A
Rationale: The correct answer is to insert the enema tube 4 inches. Enema tubing must be passed beyond the internal sphincter, which is typically around 4 inches in an adult. Inserting the tube only 2 inches is not far enough to reach this point. On the other hand, inserting the tube 6 or 8 inches is too far and might cause trauma to the bowel, which is unnecessary for a flatus-reducing enema. Therefore, the correct insertion depth of the enema tube is crucial to ensure effectiveness and safety in providing the intended treatment.
2. A nurse is planning task assignments for the day. Which assignment is the least appropriate for the nursing assistant?
- A. Assisting a client with dysphagia in eating
- B. Ambulating a client with Parkinson's disease
- C. Providing hygiene to a client with dementia
- D. Assisting a client with an above-the-knee amputation in showering
Correct answer: A
Rationale: The least appropriate assignment for a nursing assistant would be assisting a client with dysphagia in eating. This task requires specialized skills and knowledge to prevent complications such as choking and aspiration. Ambulating a client with Parkinson's disease, providing hygiene to a client with dementia, and assisting a client with an above-the-knee amputation in showering are tasks that a nursing assistant can safely perform without significant risk of complications. Assisting a client with dysphagia in eating involves higher risks and requires specific training, making it the least appropriate choice for a nursing assistant.
3. Which of the following clients would be most appropriate for an LPN to assign to a nursing assistant?
- A. an 18-year-old client with a femur fracture who is just returning to the floor from the recovery unit
- B. an 84-year-old client 2 days post-op after knee replacement surgery who needs help ambulating
- C. a 35-year-old client who is suffering from an acute asthma attack
- D. a 20-year-old client with Cystic Fibrosis who needs an early morning sputum sample collection
Correct answer: D
Rationale: Collecting sputum samples on stable clients is within the scope of practice for an LPN. This task does not require immediate intervention or assessment by an RN or medical provider. An RN should perform the initial assessment on any client immediately post-op as it requires a higher level of assessment and monitoring. A client suffering from an acute asthma attack should be attended to by an RN or medical provider due to the potential severity and need for prompt intervention. Assigning a medically stable client who needs help ambulating to a nursing assistant is appropriate as it falls within their scope of practice and allows the LPN to focus on tasks that require their expertise.
4. A nursing care plan for a client with sleep problems has been implemented. All of the following should be expected outcomes except:
- A. the client reports no episodes of awakening during the night.
- B. the client falls asleep within 1 hour of going to bed.
- C. the client reports satisfaction with their amount of sleep.
- D. the client rates sleep as an 8 or more on the visual analog scale.
Correct answer: B
Rationale: An expected outcome for a nursing care plan targeting sleep problems is that the client reports no episodes of awakening during the night, the client reports satisfaction with their amount of sleep, and the client rates sleep as an 8 or more on the visual analog scale. Falling asleep within 1 hour of going to bed is not necessarily an expected outcome. While it is generally desirable for individuals to fall asleep within a reasonable time frame, this specific timeframe may vary among individuals, and it is not a strict criterion for successful sleep outcomes. Therefore, the correct answer is that the client falls asleep within 1 hour of going to bed, as this is not a definitive measure of the effectiveness of the nursing care plan for sleep problems.
5. A health care provider asks the nurse caring for a client with a new colostomy to request the hospital's stoma nurse to visit the client and assist with colostomy care. The nurse initiates the consultation, understanding that the stoma nurse will be able to influence the client because of which type of power?
- A. Expert power
- B. Referent power
- C. Coercive power
- D. Reward power
Correct answer: A
Rationale: Power is the ability to influence others to achieve goals. Expert power results from knowledge and skills that one possesses that are needed by others. In this scenario, the stoma nurse's expertise in colostomy care gives them the ability to influence the client effectively. Reward power is based on the ability to grant rewards and favors, which is not applicable in this situation. Coercive power is based on fear and the ability to punish, which is not the case in seeking assistance for colostomy care. Referent power results from followers' desire to identify with a powerful person, which is not the primary influence in this context.
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