NCLEX-PN
NCLEX PN Test Bank
1. While receiving an infusion of cefazolin sodium, the client complained of itchy skin. The nurse observed warm, flushed skin with a red rash on the arms, chest, and back. The health care provider was promptly notified.
- A. The client is apparently allergic to cefazolin sodium, as indicated by warm, flushed skin and a rash on the arms, chest, and back.
- B. The client had an allergy to cefazolin sodium.
- C. The health care provider was notified because a rash developed while the client was receiving cefazolin sodium.
- D. During an infusion of cefazolin sodium, the client complained that his skin was itchy. The client's skin was warm and flushed, with a red rash on the arms, chest, and back. The health care provider was notified.
Correct answer: D
Rationale: Accurate and objective documentation is essential during an incident report. Choice A makes an assumption of allergy based on subjective interpretation, which is not appropriate. Choice B states a conclusion without proper documentation. Choice C is incomplete as it fails to provide a detailed account of the observed symptoms. Choice D offers a precise description of the client's symptoms, actions taken, and notification of the healthcare provider, making it the most suitable documentation choice.
2. Which of the following provides the framework for confidentiality and the client's right to privacy?
- A. Health Insurance Portability and Accountability Act
- B. CDC Surveillance Programs
- C. American Nurses Association Code of Ethics
- D. Durable Power of Attorney for Health Care
Correct answer: A
Rationale: The correct answer is the Health Insurance Portability and Accountability Act (HIPAA). HIPAA is the federal statute that outlines client confidentiality and the client's right to privacy. It establishes national standards to protect individuals' medical records and personal health information. The American Nurses Association Code of Ethics emphasizes principles of nursing ethics but does not serve as a legal framework for confidentiality and privacy. CDC Surveillance Programs focus on disease surveillance and control at a public health level and are not directly related to individual client privacy. The durable power of attorney for health care pertains to granting legal decision-making authority to another individual in healthcare matters, rather than addressing confidentiality and privacy rights.
3. A syringe pump is a type of electronic infusion pump used to infuse fluids or medications directly from a syringe. This device is commonly used for:
- A. solutions administered in obstetrics.
- B. dilute antibiotics.
- C. large volumes of IV solutions.
- D. the neonatal and pediatric populations.
Correct answer: D
Rationale: The correct answer is 'the neonatal and pediatric populations.' Syringe pumps are commonly used in neonatal and pediatric populations because they allow for precise infusion of small volumes of medications or fluids at controlled rates. This is crucial for ensuring safety and accuracy in these delicate populations. Choice A is incorrect because syringe pumps are not limited to obstetrics; they are used in various healthcare settings. Choices B and C are incorrect because syringe pumps are not typically used for dilute antibiotics or large volumes of IV solutions. Instead, they are preferred for delivering small volumes accurately, making them ideal for neonatal and pediatric care.
4. When removing a client's gown with an intravenous line, what should the nurse do?
- A. temporarily disconnect the intravenous tubing at a point close to the client and thread it through the gown
- B. cut the gown with scissors
- C. thread the bag and tubing through the gown sleeve, keeping the line intact
- D. temporarily disconnect the tubing from the intravenous container and thread it through the gown
Correct answer: C
Rationale: The correct action when removing a client's gown with an intravenous line is to thread the bag and tubing through the gown sleeve while keeping the line intact. This method ensures that the system remains sterile and reduces the risk of infection. Temporarily disconnecting the tubing at a point close to the client or from the container introduces the potential for contamination. Cutting the gown with scissors should only be done in emergencies as it is not a standard practice and can compromise the integrity of the intravenous line. Therefore, the most appropriate and safe method is to thread the bag and tubing through the gown sleeve.
5. What is the role of an incident report in risk management?
- A. To provide liability protection.
- B. To provide data for analysis by a risk manager to determine how future problems can be avoided.
- C. To discipline staff for errors.
- D. All of the above.
Correct answer: B
Rationale: The correct answer is B. Incident reports play a crucial role in risk management by providing data for analysis to prevent future problems. They are not primarily for liability protection (A) or disciplining staff (C). Therefore, choice B is the most appropriate answer. Choosing option D is incorrect because incident reports do not solely exist for all the mentioned purposes, but primarily to provide data for analysis and preventive actions.
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