NCLEX-PN
NCLEX PN Test Bank
1. A client with a left arm fracture complains of severe diffuse pain that is unrelieved by pain medication. On further assessment, the nurse notes that the client experiences increased pain during passive motion compared with active motion of the left arm. Based on these assessment findings, which action should the nurse take first?
- A. Contacting the health care provider
- B. Checking if it is time for more pain medication
- C. Encouraging the client to continue active range of motion exercises of the left arm
- D. Repositioning the client for comfort
Correct answer: A
Rationale: The correct answer is to contact the health care provider. The client with early acute compartment syndrome typically complains of severe diffuse pain that is unrelieved by pain medication. Additionally, the affected client experiences greater pain during passive motion compared to active motion. In this situation, it is crucial to notify the health care provider immediately for further evaluation and intervention. Contacting the health care provider is essential to ensure timely diagnosis and appropriate management of the condition. Checking for more pain medication, encouraging active range of motion exercises, or repositioning the client may not address the underlying issue of acute compartment syndrome and could delay necessary interventions. Therefore, the priority action should be to involve the healthcare provider for prompt assessment and treatment.
2. When making an occupied bed, what is important for the nurse to do?
- A. keep the bed in the low position.
- B. use a bath blanket or top sheet for warmth and privacy
- C. constantly keep side rails raised on both sides.
- D. move back and forth from one side to the other when adjusting the linens.
Correct answer: B
Rationale: When making an occupied bed, using a bath blanket or top sheet is important as it keeps the client warm and provides privacy, ensuring their comfort and dignity. Keeping the bed in the low position is crucial for the safety of the client, preventing falls and injuries. Constantly keeping side rails raised on both sides is unnecessary and may restrict the client's movement unnecessarily. Moving back and forth from one side to the other when adjusting the linens is inefficient and disrupts the workflow; it is more effective to work systematically from one side to the other to ensure proper bed-making.
3. Which of the following lab values is associated with a decreased risk of cardiovascular disease?
- A. high HDL cholesterol
- B. low HDL cholesterol
- C. low total cholesterol
- D. low triglycerides
Correct answer: B
Rationale: High HDL cholesterol is associated with a decreased risk of cardiovascular disease because HDL cholesterol is known as 'good' cholesterol. It helps remove other forms of cholesterol, like LDL cholesterol, from the bloodstream, reducing the risk of plaque buildup in the arteries. Low HDL cholesterol (Choice B) is actually a risk factor for cardiovascular disease because it means there is less of the 'good' cholesterol to perform its protective functions. Low total cholesterol (Choice C) and low triglycerides (Choice D) are not necessarily associated with a decreased risk of cardiovascular disease, as the balance and types of cholesterol play a more crucial role in heart health.
4. A client who is immobilized secondary to traction is complaining of constipation. Which of the following medications should the nurse expect to be ordered?
- A. Advil
- B. Anasaid
- C. Clinocil
- D. Colace
Correct answer: D
Rationale: Colace is a stool softener that acts by pulling more water into the bowel lumen, making the stool soft and easier to evacuate. In the given scenario of constipation in an immobilized client, a stool softener like Colace is the appropriate choice to help facilitate bowel movements. Advil and Anasaid are nonsteroidal anti-inflammatory drugs (NSAIDs) used for pain relief, not for constipation. Clinocil is not a recognized medication for constipation relief.
5. An LPN is having a conflict with another nurse during her shift. She has tried to discuss the issues with the nurse with no resolution. What is the most appropriate way for the LPN to proceed?
- A. Report the conflict to the director of nursing over the unit.
- B. Report the conflict to the assigned charge nurse of the unit.
- C. Report the conflict to the nurse manager of the unit.
- D. Discuss the conflict with the other nurse to attempt resolution of the issue.
Correct answer: B
Rationale: In this scenario, the most appropriate way for the LPN to proceed is to report the conflict to the assigned charge nurse of the unit. Following the chain of command is crucial in a professional setting to address conflicts effectively. Reporting the issue to the charge nurse, who is the immediate supervisor, allows for a structured approach to resolving the conflict. Reporting directly to higher levels such as the director of nursing or nurse manager may bypass the appropriate hierarchy and could create unnecessary tension. Attempting to resolve the issue independently with the other nurse may not be effective if previous attempts have failed, making it essential to involve the immediate supervisor.
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