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. In an emergency situation where a client is unconscious and requires immediate surgery, what action is necessary with regard to informed consent?
- A. The healthcare team will proceed with the surgery as consent is not needed in emergencies.
- B. The healthcare team will wait until the client's family can be contacted for consent.
- C. The healthcare team will contact the hospital clergy to provide informed consent.
- D. The healthcare team will obtain consent from the client's legal guardian before proceeding.
Correct answer: A
Rationale: In emergency situations where obtaining consent is not possible due to the client's condition, healthcare providers are allowed to perform life-saving procedures without informed consent. It is assumed that the client would want to receive necessary treatment to save their life. Therefore, the correct action is for the healthcare team to proceed with the surgery as consent is not needed. Waiting to contact the client's family for consent can delay life-saving treatment, risking the client's life. Contacting the hospital clergy for consent is unnecessary and can cause further delays. Obtaining consent from the client's legal guardian is not feasible in this critical situation and may lead to a delay in providing essential care.
3. Which of the following neurological disorders is characterized by writhing, twisting movements of the face and limbs?
- A. epilepsy
- B. Parkinson's
- C. multiple sclerosis
- D. Huntington's chorea
Correct answer: D
Rationale: Huntington's chorea is a neurological disorder characterized by writhing, twisting movements of the face and limbs, known as chorea. Epilepsy is characterized by seizures, not writhing, twisting movements. Parkinson's disease presents with tremors, rigidity, and bradykinesia, not writhing, twisting movements. Multiple sclerosis affects the central nervous system but does not typically involve writhing, twisting movements. Therefore, the correct answer is Huntington's chorea as it specifically manifests with these characteristic movements.
4. Which situation is an example of the use of evidence-based practice in the delivery of client care?
- A. Encouraging a client who has had a stroke to consume thickened liquids and soft foods
- B. Picking up a dislodged radiation implant with long-handled forceps and placing it in a lead container to minimize radiation exposure
- C. Pouring 1 to 2 mL of sterile solution that will be used for wound cleansing into a plastic-lined waste receptacle before pouring the solution into a sterile basin
- D. Blowing on a fingerstick site to dry it after cleaning the site with an alcohol swab
Correct answer: C
Rationale: Evidence-based practice is an approach that integrates client preferences, clinical expertise, and the best research evidence to deliver quality care. Pouring sterile solution into a plastic-lined waste receptacle before using it for wound cleansing reflects evidence-based practice by preventing the entrance of harmful bacteria into the wound. Option A is incorrect because encouraging a stroke client to consume thickened liquids and soft foods is appropriate, not thin liquids and foods that pose a choking risk. Option B is incorrect as picking up a radiation implant with long-handled forceps to minimize radiation exposure is a safety measure, not evidence-based practice. Option D is incorrect because blowing on a fingerstick site after cleaning can recontaminate the site, which goes against best practices in infection control.
5. The nurse on the 3-11 shift is assessing the chart of a client with an abdominal aneurysm scheduled for surgery in the morning and finds that the consent form has been signed, but the client is unclear about the surgery and possible complications. Which is the most appropriate action?
- A. Call the surgeon and ask them to see the client to clarify the information
- B. Explain the procedure and complications to the client
- C. Check the physician's progress notes to see if understanding has been documented
- D. Check with the client's family to see if they understand the procedure fully
Correct answer: A
Rationale: The most appropriate action in this scenario is to call the surgeon and ask them to see the client to clarify the information. It is the responsibility of the physician to explain and clarify the procedure to the client, ensuring informed consent. Answer B is incorrect as nurses should not provide detailed medical explanations beyond their scope of practice. Answer C is incorrect as the physician's notes may not capture the client's current understanding accurately. Answer D is incorrect because the client's own understanding, not the family's, is crucial for informed decision-making regarding the surgery.
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