NCLEX-PN
Nclex PN Questions and Answers
1. A client with cancer is transported to the radiology department for a bone scan to determine whether the cancer has metastasized to bone. While the client is in the radiology department, the client's wife arrives for a visit and asks what test is being performed on the client. What should the nurse tell the wife?
- A. A bone scan is being performed.
- B. She can read the client's medical record to determine what the health care provider prescribed.
- C. The radiology department is not clear as to which test has been prescribed.
- D. She will have to discuss the prescribed test with the client.
Correct answer: D
Rationale: In healthcare, confidentiality is crucial. Without the client's consent, nurses cannot disclose confidential information to anyone else, even to family members. Therefore, the appropriate response is to inform the client's wife that she will have to discuss the test with the client directly. It is not appropriate to disclose sensitive medical information without the client's permission. Offering the wife to read the medical record is a violation of privacy and confidentiality. Indicating that the radiology department is unclear about the prescribed test is inaccurate and does not uphold confidentiality. Moreover, it is not the responsibility of another department to disclose medical information; it is the duty of the healthcare provider and the client to discuss such matters.
2. Which of the following syndromes associated with incomplete lesions of the spinal cord results from damage to one-half of the spinal cord?
- A.
- B. posterior cord syndrome
- C. central cord syndrome
- D. cauda equina syndrome
Correct answer: A
Rationale:
3. Which of these would be the most appropriate way to document a client's refusal of medication?
- A. "Heparin refused during shift. Risks reviewed."?
- B. "The client refused the heparin injection when I tried to administer it. She yelled at me, saying, 'I do not want that injection right now!' and told me to leave the room. I explained the risks of not taking the medication. She seemed very annoyed that I tried to give it at that time. I will attempt again later in my shift."?
- C. "Subcutaneous Heparin injection was attempted to be given to the client per the physician's order. Client refused, stating, 'I do not want that injection.' Potential risks for refusing the medication were reviewed with the client, and the client verbalized understanding."?
- D. "Ct stated she did not want the SQ heparin inj at this time. Risks of not taking this med were reviewed with the ct, and the ct verbalized understanding."?
Correct answer: C
Rationale: The most appropriate way to document a client's refusal of medication should include details such as the medication, the client's statement of refusal, and the review of potential risks. Choice C accurately captures all these essential elements, making it the correct answer. Choice A lacks details about the client's refusal and the review of risks. Choice B includes unnecessary emotional descriptions and a plan of action that might not be appropriate. Choice D uses abbreviations that may not be universally understood, lacks proper punctuation, and also does not provide a detailed account of the refusal and the review of risks.
4. During a hospital program about in vitro fertilization, a television crew arrives to film for a series on hospital services. What action should the nurse conducting the program take?
- A. Ask the television crew to interview the individuals attending the program individually.
- B. Allow the television crew to videotape the program as long as they do not publicize that the program is about in vitro fertilization.
- C. Explain to the television crew that videotaping is not allowed.
- D. Allow the television crew to videotape the program.
Correct answer: C
Rationale: Privacy is a client's right to be free from unwanted intrusion into their private affairs. Videotaping constitutes an invasion of a client's privacy, and written permission is required from the client for actions such as photographing or videotaping. Therefore, the nurse must explain to the television crew that videotaping is not allowed to protect the attendees' privacy. Option A is incorrect as it still involves recording the individuals, breaching their privacy. Option B is incorrect because allowing videotaping without consent violates privacy rights. Option D is incorrect as it disregards the need for consent and privacy protection.
5. A nurse discovers that another nurse has administered an enema to a client even though the client told the nurse that he did not want one. Which is the most appropriate action for the nurse to take?
- A. Report the incident to the nursing supervisor
- B. Confront the nurse who gave the enema and inform the nurse that she may face charges of battery
- C. Tell the client that the nurse did the right thing in giving the enema
- D. Contact the client's health care provider
Correct answer: A
Rationale: Battery is any intentional touching of a client without the client's consent, which violates the client's rights. If a nurse discovers such an incident, they should report it to the nursing supervisor. Confronting the nurse and threatening charges of battery could lead to unnecessary conflict. Telling the client that the nurse did the right thing is incorrect as it goes against the client's wishes. While the health care provider may need to be notified eventually, the first step should be reporting the incident to the nursing supervisor to address the violation appropriately.
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