NCLEX-PN
2024 Nclex Questions
1. Why is the intravenous route potentially the most dangerous route of drug administration?
- A. IV infiltration may occur.
- B. it allows for rapid administration of a drug.
- C. rapid administration of a drug can lead to toxicity
- D. it is the most commonly used route in hospitals.
Correct answer: C
Rationale: The correct answer is C: rapid administration of a drug can lead to toxicity. When a drug is administered intravenously, it has 100% bioavailability, entering the bloodstream immediately and increasing the risk of toxicity if not carefully monitored. While IV infiltration (choice A) can cause tissue damage, it is not typically life-threatening. Choice B is incorrect as the speed of administration is not the primary reason for the danger; it is the immediate and full dose reaching the bloodstream. Choice D is incorrect as the popularity of the route does not inherently make it more dangerous.
2. Upon arrival at the emergency room, the client presents with severe burns to the left arm, hands, face, and neck. What action should take priority?
- A. Starting an IV
- B. Applying oxygen
- C. Obtaining blood gases
- D. Medicating the client for pain
Correct answer: B
Rationale: In a client with severe burns to the face and neck, airway assessment and supplemental oxygen are crucial. Therefore, applying oxygen is the priority to ensure adequate oxygenation for the client. This intervention takes precedence over other actions to stabilize the client's condition. Starting an IV for fluid resuscitation is the next appropriate step following ensuring oxygenation (Choice A). While pain management is important, it is a secondary priority after ensuring oxygenation and fluid resuscitation, making medicating the client for pain a later intervention (Choice D). Obtaining blood gases (Choice C) is not the immediate priority in this scenario and would typically be ordered by the healthcare provider based on the client's condition and response to initial interventions.
3. When assisting a client in gaining insight into anxiety, what should the nurse do?
- A. Help the client relate anxiety to specific triggers.
- B. Ask the client to describe events that precede increased anxiety.
- C. Instruct the client to practice relaxation techniques.
- D. Confront the client's resistive behavior.
Correct answer: B
Rationale: To assist a client in gaining insight into anxiety, it is crucial to identify triggers or events that lead to increased anxiety. This approach helps the client recognize causal factors contributing to their anxiety, promoting self-awareness and understanding. Choice A is incorrect because it should focus on triggers rather than specific behaviors. Choice C is incorrect as it emphasizes managing anxiety through relaxation techniques rather than understanding its roots. Choice D is incorrect as it addresses resistive behavior rather than exploring the causes of anxiety.
4. How can the nurse best communicate to a client that he or she has been listening?
- A. restating the main feeling or thought the client has expressed
- B. making a judgment about the client's problem
- C. offering a leading question such as, 'And then what happened?'
- D. saying, 'I understand what you're saying.'
Correct answer: A
Rationale: The best way for the nurse to communicate to a client that he or she has been listening is by restating the main feeling or thought the client has expressed. Restating helps the client validate the nurse's understanding of the communication, demonstrating active listening skills. Making judgments about the client's problem, as suggested in Choice B, can hinder effective communication by introducing bias and potential misinterpretation. Offering a leading question like in Choice C is not ideal for confirming understanding; it rather seeks more information. Choice D, simply saying 'I understand what you're saying,' may not convey active listening as effectively as restating the client's main feelings or thoughts, as it lacks the validation component present in restating.
5. The nurse is working with families who have been displaced by a fire in an apartment complex. What is the priority intervention during the initial assessment?
- A. Provide a liaison to meet housing needs.
- B. Attentively listen when clients describe their feelings.
- C. Offer nurturing support for clients who are confused by the events.
- D. Provide structure for clients exhibiting moderate to severe anxiety.
Correct answer: A
Rationale: The correct answer is to provide a liaison to meet housing needs. In the initial assessment after a disaster like a fire, ensuring basic needs such as housing, clothing, and food are met is the priority. Once the physical needs are addressed, the nurse can then focus on assisting clients in managing the psychological effects of loss. Choices B, C, and D are not the priority during the initial assessment as addressing housing needs should come first to provide a sense of stability and security for the affected families.
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