NCLEX-PN
NCLEX PN Test Bank
1. A nursing instructor asks a nursing student to describe accountability. Which statement(s) by the student indicate(s) an accurate description of accountability?
- A. Check the unit policy for the protocol for the care of clients who have been sexually assaulted.
- B. Ask a medical assistant.
- C. Call the nurse in charge of the day shift.
- D. Ask the police officers who brought the client to the center.
Correct answer: A
Rationale: Accountability in nursing involves taking responsibility for one's actions and decisions. In this scenario, checking the unit policy for the protocol related to the care of sexually assaulted clients demonstrates accountability. Policies and protocols provide guidance on appropriate actions and responsibilities in specific situations. Asking a medical assistant, calling the day shift nurse in charge, or consulting police officers are not appropriate actions to demonstrate accountability in this context. Seeking further clarification from the agency nursing supervisor on the night shift after reviewing the policy or protocol would be a more suitable course of action.
2. A 10-year-old boy has been diagnosed with a congenital heart defect. Which of the following clinical signs does not indicate CHF?
- A. Increased body weight
- B. Elevated heart rate
- C. Lower extremity edema
- D. Compulsive behavior
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. Which of the following enzymes is indicative of pancreatitis?
- A. alkaline phosphatase
- B. acid phosphatase
- C. creatine phosphokinase
- D. amylase
Correct answer: D
Rationale: Amylase is elevated in conditions of pancreatic inflammation, such as pancreatitis. Pancreatitis is characterized by the inflammation of the pancreas, leading to the leakage of amylase into the bloodstream. Elevated levels of amylase are a key diagnostic marker for pancreatitis. Alkaline phosphatase is associated with liver and bone conditions, not pancreatitis. Acid phosphatase is more related to prostate health and is not specific to pancreatitis. Creatine phosphokinase is found in tissues like muscle and brain, and elevated levels are seen in conditions like muscle injury or heart attack, not pancreatitis.
4. What is the most effective way to prevent skin breakdown?
- A. assistive devices
- B. repositioning
- C. topical medications
- D. avoiding tape and bandages
Correct answer: V
Rationale: Repositioning is the most effective way to prevent skin breakdown. Repositioning helps relieve pressure on specific areas of the skin, reducing the risk of developing pressure ulcers. While assistive devices (Choice A) may be beneficial in some cases, they are not universally as effective as repositioning. Topical medications (Choice C) are primarily used for treating skin conditions and are not the primary focus for preventing skin breakdown. Avoiding tape and bandages (Choice D) is crucial to prevent skin irritation, but repositioning remains the most effective method to prevent skin breakdown.
5. For which of the following conditions might blood be drawn to assess uric acid levels?
- A. asthma
- B. gout
- C. diverticulitis
- D. meningitis
Correct answer: B
Rationale: Uric acid levels are commonly assessed in patients with gout. Gout is a type of arthritis caused by the buildup of uric acid crystals in the joints, leading to inflammation and pain. Monitoring uric acid levels helps in diagnosing and managing gout. Asthma, diverticulitis, and meningitis are not conditions where blood tests for uric acid levels are typically necessary. Asthma is a respiratory condition, diverticulitis involves inflammation of the digestive tract, and meningitis is an infection of the meninges in the brain and spinal cord.
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