a nurse is reviewing the notes written by a nurse on a previous shift which note in the clients record reects the correct use of guidelines for docume
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Nursing Elites

NCLEX-PN

Nclex Exam Cram Practice Questions

1. A nurse is reviewing the notes written by a nurse on a previous shift. Which note in the client's record reflects the correct use of guidelines for documentation?

Correct answer: C

Rationale: Quality documentation and reporting require information to be factual, accurate, complete, current, and organized. Choice C, 'The client's intake was 360 mL,' reflects the correct use of guidelines for documentation as it provides a specific and measurable observation. This note meets the criteria for quality documentation by being specific and quantifiable. Choices A, B, and D lack specificity and quantifiability. Choice A includes a subjective term 'well,' choice B uses 'seems' indicating uncertainty, and choice D uses a vague term 'large' without quantifying the amount.

2. The nurse is preparing to administer IV Vancomycin to a client. Which of the following nursing actions should be taken first?

Correct answer: D

Rationale: Before administering any medication, including IV Vancomycin, it is crucial to ensure that the client is not allergic to the medication. This is the most critical action to prevent any potential allergic reactions. While performing a physical assessment is important, it may not be as time-sensitive as checking for allergies. Obtaining lab values related to renal function is also significant with Vancomycin due to its potential nephrotoxicity, but ensuring the client's safety by checking for allergies takes precedence. Reviewing peaks and troughs is important for monitoring drug levels, but it is a secondary step compared to checking for allergies prior to administration.

3. When planning task assignments for five clients on the skilled nursing unit in a long-term care facility, which task should a licensed practical nurse (LPN) assign to another LPN?

Correct answer: B

Rationale: When assigning tasks, the nurse must consider the skills and educational level of the nursing staff. The nursing assistant may be assigned tasks like caring for a confused client, assisting with a shower or a bed bath, ambulating a client with a cane, and accompanying a client to physical therapy. The LPN is educated to administer medications like regular insulin in accordance with a sliding scale. This task requires a higher level of training and knowledge than the tasks that can be delegated to a nursing assistant. Administering insulin involves assessing blood glucose levels, calculating dosages, and understanding the effects of insulin therapy on the client's condition. Therefore, the correct answer is administering regular insulin to a client with diabetes mellitus. Choices A, C, and D involve tasks that are within the scope of practice of a nursing assistant, not an LPN.

4. When a client's postoperative pain seems to be getting worse due to grief over the recent death of their spouse, what should the nurse consider?

Correct answer: D

Rationale: The correct answer is developing interventions for grief and loss. In this scenario, the client's pain is not solely sensory but also affective due to grieving over the death of their spouse. It is essential to address the emotional component of pain by providing support and interventions for grief and loss. Referring the client for a psychiatric consult may not be necessary as grieving is a normal response to such a significant loss. Calling the physician for an increased dosage of pain medication or a sedative solely focuses on the sensory aspect of pain and does not address the underlying emotional distress.

5. To assess a client's ankle ROM, which ROM exercises should the nurse have them perform?

Correct answer: D

Rationale: The correct answer is extension, flexion, inversion, and eversion. These exercises help assess the full range of motion of the ankles. Flexion and extension evaluate the bending and straightening movements of the ankle joint, respectively. Inversion and eversion assess the inward and outward movements of the foot at the ankle joint. Hyperextension, abduction, and adduction are not specific movements of the ankle joint, making choices A and B incorrect. External and internal rotation are movements more related to joints like the hip or shoulder, not the ankle, making choice C incorrect.

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