a nurse enters a clients room to administer a medication that has been prescribed by the health care provider the client asks the nurse about the medi
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Nursing Elites

NCLEX-PN

Nclex PN Questions and Answers

1. A nurse enters a client's room to administer a medication that has been prescribed by the health care provider. The client asks the nurse about the medication. Which response by the nurse is appropriate?

Correct answer: B

Rationale: A client has the right to be informed of the medication name, purpose, action, and potential undesirable effects of a prescribed medication. The nurse should provide adequate information to the client. Choice B is the correct answer as it includes the medication name, its purpose (promoting urination and eliminating excess fluid), and a potential side effect (alteration in electrolyte levels) with a plan for managing it (increasing potassium in the diet). This response demonstrates thorough and complete information. Choice A provides some information but lacks details on potential side effects and dietary adjustments. Choice C is vague and does not provide specific details about the medication. Choice D deflects the client's question and does not fulfill the client's right to information.

2. A 10-year-old boy has been diagnosed with a congenital heart defect. Which of the following clinical signs does not indicate CHF?

Correct answer: D

Rationale: Compulsive behavior is not a clinical sign typically associated with congestive heart failure (CHF). CHF commonly presents with symptoms such as increased body weight due to fluid retention, elevated heart rate as the heart works harder to pump blood effectively, and lower extremity edema caused by fluid buildup. While behavioral changes can occur in response to illness, compulsive behavior is not a typical indicator of CHF. Choices A, B, and C are more commonly linked to CHF and should be monitored in patients with this condition.

3. What condition is mammography used to detect?

Correct answer: B

Rationale: Mammography is specifically used to detect tumors or abnormal growths, especially in breast tissue. It is not a tool for identifying pain, edema, or epilepsy. Therefore, the correct answer is 'tumor.' Pain is a symptom, edema is swelling, and epilepsy is a neurological disorder; none of these are conditions typically detected through mammography.

4. A nursing assistant who has been employed in the long-term care center for 8 weeks is consistently taking extended lunch breaks. The nursing assistant's behavior has caused problems with client care during lunch hours. What is the appropriate way for the nurse to deal with this situation?

Correct answer: D

Rationale: Taking extended lunch breaks is an unacceptable behavior, especially when it affects client care. The appropriate way for the nurse to deal with this situation is to meet with the nursing assistant to discuss the behavior and initiate problem-solving measures. This direct approach allows for open communication and the opportunity to address the issue effectively. Ignoring the situation (Choice A), asking other staff members to cover (Choice C), or documenting the problem in the nursing assistant's personnel file (Choice B) are not effective solutions. Ignoring the behavior does not address the issue, asking others to cover may not solve the problem at its root, and documenting the problem should come after attempting to resolve the issue through communication and problem-solving first.

5. After delivery, a newborn undergoes an Apgar assessment. What does this scoring system evaluate?

Correct answer: B

Rationale: The Apgar scoring system, developed by Virginia Apgar, an anesthesiologist, evaluates newborns based on five criteria: heart rate, respiratory effort, color, muscle tone, and reflex irritability. These parameters provide a quick and simple assessment of a newborn's overall condition and the need for immediate medical attention. Choices B, C, and D are incorrect as they do not encompass the essential elements evaluated by the Apgar scoring system.

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