NCLEX-PN
NCLEX PN Test Bank
1. The nurse is teaching a client about erythema infectiosum. Which of the following factors is not correct?
- A. There is no rash.
- B. The disorder is uncommon in adults.
- C. There is no fever.
- D. There is sometimes a 'slapped face' appearance.
Correct answer: B
Rationale: The correct answer is B: 'The disorder is uncommon in adults.' Erythema infectiosum, also known as Fifth's disease, is more common in children than in adults. It typically presents with a rash on the face that gives a 'slapped cheek' or 'slapped face' appearance. Fever may be present, and there is a characteristic rash associated with the condition. Therefore, the statement 'The disorder is uncommon in adults' is incorrect, making it the correct answer. The other statements are true regarding erythema infectiosum, making them incorrect choices. There is indeed a rash associated with erythema infectiosum, which can be a prominent feature. Fever may also be present in individuals with this condition. Additionally, the 'slapped face' appearance is a classic characteristic of erythema infectiosum.
2. The nurse is caring for a client recovering from a stroke who recently regained consciousness. The client is having difficulty communicating verbally with the team. Which of the following actions would be least appropriate?
- A. Begin client data collection before receiving the physician's order for the referral.
- B. Use documents to provide information for the referral.
- C. Wait for the physician's order for speech therapy before assisting with the appropriate documentation.
- D. Participate in the client referral process.
Correct answer: C
Rationale: In this scenario, the least appropriate action would be to wait for the physician's order for speech therapy before assisting with the appropriate documentation. The nurse should start by collecting client data without needing the physician's order, use documents to provide information for the referral, and actively participate in the client referral process. Waiting for the physician's order unnecessarily delays potentially crucial therapy for the client's recovery, affecting the timeliness and effectiveness of care. Therefore, choice C is the least appropriate as immediate action is required in such situations.
3. Which of the following is not one of the four categories related to client care plans?
- A. privacy
- B. evaluation
- C. diagnosis
- D. outcome
Correct answer: A
Rationale: The four categories related to client care plans are diagnosis, intervention, outcome, and evaluation. Privacy is not typically considered a distinct category in client care plans, as it is more of a fundamental aspect that underlies all care provided to clients. Choices B, C, and D are directly related to the components of client care plans, making them incorrect answers in this context.
4. What is the appropriate intervention for a client who is restrained?
- A. Remove the restraints and provide skin care every hour.
- B. Document the condition of the client's skin every 3 hours.
- C. Assess the restraint every 30 minutes
- D. Tie the restraint to the side rails.
Correct answer: C
Rationale: The correct intervention when a client is restrained is to assess the restraint every 30 minutes. This ensures the safety and well-being of the client by checking for proper fit, circulation, and signs of distress. Removing restraints and providing skin care every hour may not be necessary and could increase the risk of skin breakdown. Documenting the skin condition every 3 hours is important but not the immediate intervention needed when a client is restrained. Tying the restraint to the side rails is unsafe and can cause harm to the client, as restraints should be secured to the bed frame or an immovable part of the bed.
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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