NCLEX-PN
Nclex Exam Cram Practice Questions
1. What does it mean to be a nursing advocate?
- A. makes decisions for others.
- B. encourages persons to make decisions for themselves and acts with or on behalf of the person to support those decisions.
- C. manages the care of others.
- D. is the legal representative for a person.
Correct answer: B
Rationale: A nursing advocate does not make decisions for others but instead empowers individuals to make decisions for themselves. By encouraging individuals to make their own decisions and supporting them in this process, nursing advocates uphold the principle of self-determination. This approach respects the autonomy and independence of individuals in managing their care. Therefore, the correct answer is to 'encourage persons to make decisions for themselves and act with or on behalf of the person to support those decisions.' Choices A, C, and D are incorrect as they do not align with the role of a nursing advocate in promoting patient autonomy and self-determination.
2. When a client needs oxygen therapy, what is the highest flow rate that oxygen can be delivered via nasal cannula?
- A. 2 liters/minute
- B. 4 liters/minute
- C. 6 liters/minute
- D. 8 liters/minute
Correct answer: C
Rationale: The correct answer is 6 liters/minute. When a client requires oxygen therapy, the maximum flow rate that oxygen can be delivered via nasal cannula is 6 liters/minute. Nasal cannula can effectively deliver oxygen up to 6 liters/minute. Flow rates exceeding 6 liters/minute may lead to drying of the nasal passages and discomfort for the client. Higher flow rates, like 8 liters/minute, should be administered using a mask to ensure sufficient oxygenation. Options A, B, and D are incorrect as they indicate flow rates that surpass the recommended maximum for nasal cannula delivery.
3. A client has experienced a CVA with right hemiparesis and is ready for discharge from the hospital to a long-term care facility for rehab. To provide optimal continuity of care, the nurse should do all of the following except:
- A. document the current functional status
- B. have the physician fax a report to the receiving facility
- C. copy appropriate parts of the medical record for transport to the receiving facility
- D. phone a report to the facility
Correct answer: B
Rationale: To ensure optimal continuity of care for a client transitioning to a long-term care facility for rehab after a CVA, the nurse plays a crucial role in communication. Documenting the current functional status is essential for the receiving facility to plan appropriate care. Copying relevant parts of the medical record for transport provides important background information. Phoning a report directly to the facility is a direct and effective way to communicate the client's condition and care plan. However, having the physician fax a report to the receiving facility introduces an extra step that may delay essential information transfer and increase the risk of miscommunication. Therefore, it is not the optimal choice for ensuring seamless continuity of care.
4. Major competencies for the nurse giving end-of-life care include:
- A. demonstrating respect and compassion, and applying knowledge and skills in care of the family and the client.
- B. assessing and intervening to support total management of the family and client.
- C. setting goals, expectations, and dynamic changes to care for the client.
- D. keeping all sad news away from the family and client.
Correct answer: A
Rationale: In providing end-of-life care, nurses must possess essential competencies. Demonstrating respect and compassion, along with applying knowledge and skills in caring for both the family and the client, are crucial competencies. These skills help create a supportive and empathetic environment for individuals facing end-of-life situations. Choice B is incorrect because while assessing and intervening are important, they do not encompass the core competencies required for end-of-life care. Choice C is also incorrect; although setting goals and expectations is valuable, the primary focus should be on providing compassionate care. Choice D is incorrect as withholding sad news goes against the principles of honesty and transparency in end-of-life care.
5. When the healthcare provider is determining the appropriate size of a nasopharyngeal airway to insert, which body part should be measured on the client?
- A. corner of the mouth to tragus of the ear
- B. corner of the eye to top of the ear
- C. tip of the chin to the sternum
- D. tip of the nose to the earlobe
Correct answer: D
Rationale: A nasopharyngeal airway is measured from the tip of the nose to the earlobe. This measurement ensures that the airway is of the correct length to reach the nasopharynx without being too long or too short. Choices A, B, and C are incorrect as they do not provide the appropriate measurement for selecting the correct size of a nasopharyngeal airway. The distance from the corner of the mouth to the tragus of the ear (Choice A) is used to measure for an oropharyngeal airway, not a nasopharyngeal airway. Similarly, the other choices (B and C) do not correlate with the correct measurement of a nasopharyngeal airway.
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