NCLEX-PN
NCLEX PN Test Bank
1. A licensed practical nurse (LPN) in the long-term care unit who has another LPN and a nursing assistant on the nursing team is planning task assignments for the day. Which task should the nurse assign to the LPN?
- A. Monitoring a client receiving oxygen who requires frequent pulse oximetry monitoring and respiratory treatments
- B. Assisting a client who is wearing eye patches and requires assistance with hygiene measures
- C. Feeding a client on bedrest who needs assistance with feeding
- D. Turning a client who must be turned and repositioned every 2 hours
Correct answer: A
Rationale: When a nurse assigns tasks for a client's care to another staff member, the nurse is responsible for appropriately assigning tasks based on the educational level and competency of the staff member. In this scenario, the LPN should be assigned the task of monitoring a client receiving oxygen who requires frequent pulse oximetry monitoring and respiratory treatments. This is because the LPN is competent to perform these tasks and can accurately note changes in the client's condition. Tasks such as feeding a client, turning and repositioning a client, and assisting with hygiene measures, which are noninvasive interventions, can be assigned to a nursing assistant. These tasks do not require the same level of assessment and monitoring as the respiratory treatments and pulse oximetry monitoring.
2. A new nurse employed at a community hospital is reading the organization's mission statement. The new nurse understands that this statement is written for which purpose?
- A. To outline what the organization plans to accomplish
- B. To identify the policies and procedures of the organization
- C. To describe the benefits available to employees
- D. To define the rules of the organization that the employees must follow
Correct answer: A
Rationale: The correct answer is 'To outline what the organization plans to accomplish.' A mission statement expresses the purpose or reason for an organization's existence, outlining what it aims to achieve. It often includes statements of philosophy, purpose, and goals. This statement serves as a benchmark for evaluating the organization's performance. The mission statement is not meant to identify policies and procedures (Choice B) or describe employee benefits (Choice C). Choice B specifies the administrative guidelines and protocols of the organization, while Choice C pertains to the perks available to employees. Choice D is incorrect as the rules of the organization that employees must follow are usually detailed in employee handbooks or codes of conduct, not in the mission statement.
3. 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.
4. Which hormone in the urine is specifically indicative of pregnancy?
- A. estrogen
- B. progesterone
- C. testosterone
- D. human chorionic gonadotropin
Correct answer: D
Rationale: Human chorionic gonadotropin is the hormone specifically indicative of pregnancy as it is produced by the placenta after implantation. It can be detected in urine and blood samples to confirm pregnancy. Estrogen and progesterone play crucial roles in the menstrual cycle and pregnancy but are not specific indicators of pregnancy on their own. Testosterone is a hormone primarily associated with male reproductive functions and is not directly related to pregnancy, making it an incorrect choice in this context.
5. The LPN is caring for a client with an NG tube, and the RN administers evening medications through the NG tube. The client asks if he can lie down when the nurse leaves the room. What is the most appropriate response?
- A. You can lie down in 1 hour.
- B. You can lie down in 30 minutes if your NG residual is below 50 mL.
- C. You can lie down in about 30 minutes.
- D. Yes, feel free to lie down.
Correct answer: A
Rationale: After administering medication through an NG tube, the client should remain upright for 30 minutes to ensure proper absorption of the medications. Therefore, the most appropriate response is to advise the client to lie down in 1 hour. Choice B is incorrect because waiting only 30 minutes may not provide sufficient time for the medications to be fully absorbed, as the recommended time is 30 minutes. Choice C is misleading as it incorrectly suggests that lying down in about 30 minutes is acceptable, which could compromise medication effectiveness. Choice D is incorrect as it does not provide accurate information regarding the appropriate timing for lying down after NG tube medication administration, potentially leading to decreased medication absorption.
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