NCLEX-PN
NCLEX PN Test Bank
1. In a centralized decision-making process within an organization, where is the authority to make decisions vested?
- A. Every employee
- B. A few individuals, such as the board of directors
- C. Many individuals, with decisions filtering down to the individual employee
- D. All nursing employees, pharmacists, and hospital health care providers
Correct answer: B
Rationale: In a centralized decision-making process within an organization, the authority to make decisions is concentrated in a few individuals, such as the board of directors. This means that key decision-making power is held by a select group at the top of the organizational hierarchy. Choices A, C, and D are incorrect because in a centralized structure, decision-making authority is not distributed among every employee, does not filter down to individual employees, and is not shared among all nursing employees, pharmacists, or hospital health care providers. Centralized decision-making implies a more top-down approach.
2. A client turns her ankle. She is diagnosed as having a Pulled Ligament. This should be documented as a:
- A. sprain.
- B. strain.
- C. subluxation.
- D. dislocation.
Correct answer: B
Rationale: A sprain is the correct term for the excessive stretching of a ligament, which is what happens when a ligament is pulled. A strain involves muscle tissue. Subluxation refers to a partial dislocation, and dislocation is a complete displacement of bones in a joint. In this case, since it's a pulled ligament, the most appropriate term is a sprain.
3. A client with major head trauma is receiving bolus enteral feeding. The most important nursing order for this client is:
- A. measure intake and output.
- B. check albumin levels.
- C. monitor glucose levels.
- D. increase enteral feeding.
Correct answer: A
Rationale: The correct action for a client with major head trauma receiving bolus enteral feeding is to measure intake and output (I&O). Enteral feedings are hyperosmotic agents that can cause fluid shifts. Monitoring I&O is crucial to assess fluid balance, ensuring that input matches output. Checking albumin levels (choice B) is important for assessing nutritional status but is not the immediate priority in this situation. Monitoring glucose levels (choice C) is also important but not as critical as measuring I&O in this context. Increasing enteral feeding (choice D) should only be done based on a healthcare provider's order after assessing the patient's condition, not as the most important nursing order at this time.
4. Which of these statements from the caregiver of a palliative care client indicates a proper understanding?
- A. This treatment plan usually indicates a prognosis of less than 6 months.
- B. We will need to stay in the hospital to receive this level of care.
- C. The main therapeutic goals are comfort and better quality of life.
- D. The medications to treat the underlying disease will be continued.
Correct answer: C
Rationale: The correct answer is 'The main therapeutic goals are comfort and better quality of life.' This statement reflects a proper understanding of palliative care, which focuses on improving the patient's quality of life and providing comfort. It does not necessarily mean a prognosis of less than 6 months or require hospitalization. Choice A is incorrect because palliative care can be provided regardless of the prognosis. Choice B is wrong as palliative care can be administered in various settings, not just hospitals. Choice D is inaccurate as palliative care aims to improve symptoms and quality of life, so medications may be adjusted but not necessarily stopped.
5. Which of the following adverse effects should the client on Floxin be alerted to?
- A. stunting of height in teens and young adults
- B. propensity for anovulatory uterine bleeding
- C. intractable diarrhea
- D. tendon rupture
Correct answer: D
Rationale: The correct answer is tendon rupture. Floxin is a quinolone antibiotic commonly used in respiratory infections and pelvic/reproductive infections. One of the rare adverse effects associated with quinolones is tendon sheath rupture, often affecting the Achilles tendon. Therefore, patients taking Floxin should be alerted to the possibility of tendon rupture. Choices A, B, and C are incorrect as they are not typically associated with Floxin use and are not common adverse effects of quinolone antibiotics. Stunting of height is not a recognized adverse effect of Floxin. Anovulatory uterine bleeding is not a known side effect of quinolones. Intractable diarrhea is not a common adverse effect of Floxin.
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