NCLEX-PN
NCLEX PN Test Bank
1. Once the nurse has made initial rounds and checked all of the assigned clients, which client should be cared for first?
- A. A client who is scheduled for surgery at 1 p.m.
- B. A client in skeletal traction who has just received pain medication
- C. A client scheduled for physical therapy at 11 a.m.
- D. A client who is able to perform activities of daily living independently
Correct answer: A
Rationale: The priority should be given to the client who is scheduled for surgery at 1 p.m. Preparing a client for surgery involves various tasks such as physical and emotional preparation, following healthcare provider instructions, and potential last-minute changes in the surgical schedule. It is crucial to ensure the client is adequately prepared. Providing care to a client who just received pain medication can wait until the medication takes effect. Clients who are independent in performing daily activities and those scheduled for physical therapy later in the morning are not as high a priority as preparing a client for an upcoming surgery. Therefore, the client scheduled for surgery should be cared for first to ensure all necessary preparations are completed.
2. Which is the proper hand position for performing chest percussion?
- A. Use the side of the hands
- B. Flatten the hands
- C. Spread the fingers of both hands
- D. Cup the hands
Correct answer: D
Rationale: The proper hand position for performing chest percussion is to cup the hands. Cupping the hands helps produce a vibration that aids in loosening respiratory secretions effectively. This technique is essential for therapeutic chest physiotherapy. Using the side of the hands, flattening the hands, or spreading the fingers of both hands do not generate the necessary vibration required for chest percussion. These hand positions are not considered proper techniques in this context and may not provide the desired therapeutic effect.
3. How does cancer affect pain tolerance in elderly clients?
- A. Remain constant.
- B. Decrease.
- C. Increase.
- D. Cancer has no impact on pain tolerance in elderly clients.
Correct answer: B
Rationale: Pain tolerance in elderly clients with cancer is likely to decrease due to factors such as diminished adaptative capacity, increased physical discomfort, and the psychological impact of the disease. Cancer is known to cause various physical and emotional stressors that can lower the pain threshold, leading to a decrease in pain tolerance. Choices A, C, and D are incorrect because cancer and its associated effects typically result in a decrease in pain tolerance rather than remaining constant, increasing, or having no impact.
4. What is the correct instruction to give a client undergoing mammography?
- A. Do not use underarm deodorant.
- B. Wear comfortable clothing.
- C. Avoid caffeine prior to the procedure.
- D. Bring a list of current medications.
Correct answer: A
Rationale: The correct instruction for a client undergoing mammography is not to use underarm deodorant. Underarm deodorant can cause confusing shadows on the X-ray film, affecting the accuracy of the mammogram. Choices B, C, and D are incorrect. While wearing comfortable clothing is advisable, it is not the primary instruction for mammography. Avoiding caffeine and bringing a list of current medications are not specific instructions related to mammography preparation and are therefore not the correct answers.
5. Which situation is an example of the use of evidence-based practice in the delivery of client care?
- A. Encouraging a client who has had a stroke to consume thickened liquids and soft foods
- B. Picking up a dislodged radiation implant with long-handled forceps and placing it in a lead container to minimize radiation exposure
- C. Pouring 1 to 2 mL of sterile solution that will be used for wound cleansing into a plastic-lined waste receptacle before pouring the solution into a sterile basin
- D. Blowing on a fingerstick site to dry it after cleaning the site with an alcohol swab
Correct answer: C
Rationale: Evidence-based practice is an approach that integrates client preferences, clinical expertise, and the best research evidence to deliver quality care. Pouring sterile solution into a plastic-lined waste receptacle before using it for wound cleansing reflects evidence-based practice by preventing the entrance of harmful bacteria into the wound. Option A is incorrect because encouraging a stroke client to consume thickened liquids and soft foods is appropriate, not thin liquids and foods that pose a choking risk. Option B is incorrect as picking up a radiation implant with long-handled forceps to minimize radiation exposure is a safety measure, not evidence-based practice. Option D is incorrect because blowing on a fingerstick site after cleaning can recontaminate the site, which goes against best practices in infection control.
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