NCLEX-PN
Nclex PN Questions and Answers
1. A nurse calls a health care provider to report that a client with congestive heart failure (CHF) is exhibiting dyspnea and worsening of wheezing. The health care provider, who is in a hurry because of a situation in the emergency department, gives the nurse a telephone prescription for furosemide (Lasix) but does not specify the route of administration. What is the appropriate action on the part of the nurse?
- A. Calling the health care provider who gave the telephone prescription to clarify the prescription
- B. Administering the medication orally and clarifying the prescription once the health care provider has finished caring for the client in the emergency department
- C. Calling the nursing supervisor for assistance in determining the route of administration
- D. Administering the medication intravenously because this route is generally used for clients with CHF
Correct answer: A
Rationale: Telephone prescriptions involve a health care provider dictating a prescribed therapy over the telephone to the nurse. The nurse must clarify the prescription by repeating it clearly and precisely to the health care provider. The nurse then writes the prescription on the health care provider's prescription sheet or enters it into the electronic medical record. It is crucial not to interpret an unclear prescription or administer a medication by a route that has not been expressly prescribed. In this case, the nurse should call the health care provider who gave the telephone prescription to clarify the prescription, ensuring the correct route of administration is specified. Options B, C, and D are incorrect because administering the medication without clarification, seeking assistance from the nursing supervisor, or choosing an arbitrary route of administration can compromise patient safety and violate medication administration protocols.
2. Which cultural group has the highest incidence of inflammatory bowel disease (IBD)?
- A. Asians
- B. Caucasians
- C. Hispanics
- D. African Americans
Correct answer: B
Rationale: The correct answer is Caucasians. Studies have shown that Caucasians have the highest incidence of inflammatory bowel disease (IBD) compared to other cultural groups. While IBD can affect individuals from various backgrounds, the prevalence is notably higher in Caucasians. Asians, Hispanics, and African Americans have a lower incidence of IBD compared to Caucasians, making them incorrect choices in this context.
3. An Asian family has an elderly member with the latest stage of Alzheimer's disease. The physician has recommended placement in a long-term care facility, but the family refuses. Which of the following is an appropriate response by the nurse?
- A. "You really need to listen to what the physician says."?
- B. "You will get too tired to take care of him at home."?
- C. "What can I do to assist you to care for him at home?"?
- D. "You are too busy to be taking care of an elderly person."?
Correct answer: C
Rationale: The correct answer is, "What can I do to assist you to care for him at home?"? This response shows cultural sensitivity and respect for the family's values. In many Asian cultures, there is a strong tradition of caring for elders at home rather than in a long-term care facility. By offering assistance to the family in caring for their elderly member at home, the nurse shows understanding and support. Choices A, B, and D are incorrect because they do not acknowledge or respect the family's cultural beliefs and values regarding caring for elderly family members.
4. Which of the following statements describes the purpose of client restraint?
- A. Restraints are a nursing measure used to maintain client control.
- B. Restraints are an emergency intervention taken as a last resort to protect a client from imminent danger.
- C. Restraints are a therapeutic measure designed to positively reinforce client behavior.
- D. Restraints are an emergency measure that can only be taken by a nurse under the direct supervision of a physician.
Correct answer: B
Rationale: The correct answer is B. Restraints are used as an emergency intervention when all other options to protect a client from imminent danger have been exhausted. Restraints should only be used as a last resort to ensure the safety of the client and others. Choices A, C, and D are incorrect because restraints are not used to maintain control, reinforce behavior, or are exclusively taken under direct physician supervision. It is crucial to remember that restraint use should always be based on careful assessment, documentation, and adherence to legal and ethical guidelines.
5. What is a true statement about post-discharge follow-up?
- A. The nurse should ensure the client is educated on their discharge instructions.
- B. If the client seems stable, they likely do not need a follow-up visit.
- C. The physician is responsible for ensuring the client has their prescriptions upon discharge.
- D. If the client has questions, the nurse should address them before discharge.
Correct answer: A
Rationale: The correct statement is that the nurse should ensure the client is educated on their discharge instructions. This is crucial to promote continuity of care and prevent adverse events. The responsibility of educating the client falls on the nurse, not assuming stability without a follow-up visit. While the physician may prescribe medications, it is the nurse's responsibility to ensure the client has them before discharge. Instructing the client to bring up questions at a follow-up appointment is not ideal; all questions should be addressed before discharge to ensure the client's understanding and compliance.
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