NCLEX-PN
NCLEX PN Test Bank
1. The nurse should teach parents of small children that the most common type of first-degree burn is:
- A. scalding from hot bath water or spills
- B. contact with hot surfaces such as stoves and fireplaces
- C. contact with flammable liquids or gases resulting in flash burns
- D. sunburn from lack of protection and overexposure
Correct answer: D
Rationale: The most common type of first-degree burn in small children is sunburn, often due to lack of protection and overexposure to the sun. This type of burn highlights the importance of educating parents about using sunscreens and ensuring children are adequately protected from the sun's harmful rays. Choices A, B, and C describe scenarios that can lead to burns but are not the most common type of first-degree burn in small children, making them incorrect.
2. Why is client and family communication and education concerning restraints essential?
- A. confuses both groups further
- B. helps with coping and stress levels
- C. encourages cooperation with the client and family
- D. puts the responsibility on the client and family, not the nurse
Correct answer: C
Rationale: Client and family communication and education concerning restraints are essential to encourage cooperation. When the client and family understand the purpose and expected benefits of restraints, they are more likely to cooperate. This understanding can help prevent well-meaning family members from releasing restraints due to confusion or lack of information. Therefore, choice C is correct. Choices A, B, and D are incorrect because confusing both groups further, helping with coping and stress levels, and shifting responsibility to the client and family are not the primary goals of communication and education concerning restraints.
3. When suctioning a client, what is the usual amount of time the nurse should spend for each suction pass?
- A. 2 seconds
- B. 10 seconds
- C. 20 seconds
- D. 30 seconds
Correct answer: B
Rationale: Ten seconds is the usual amount of time the nurse should spend for each suction pass. Two seconds is not enough time to effectively remove secretions, while 20 and 30 seconds are too long and could lead to hypoxia and tissue trauma. Therefore, the correct choice is 10 seconds, as it strikes a balance between removing secretions adequately and minimizing the risks associated with prolonged suctioning.
4. A client has been placed in isolation because he is diagnosed with a contagious illness. The nurse should be aware that:
- A. Linens from the client's bed should be double-bagged.
- B. Meals should be served on washable dishes.
- C. Extensive isolation rarely causes psychological problems.
- D. Paper trays and plastic utensils do not prevent disease transmission.
Correct answer: A
Rationale: Isolation techniques are used to prevent or limit the spread of infection. Special handling of articles and linens soiled by any body fluid is essential. Linens should be placed in impervious bags before being removed from the client's bedside to prevent exposure of personnel and contamination of the environment. Double-bagging is required if the outside of the bag becomes contaminated. This practice ensures that potentially infectious materials are properly contained and disposed of. Choices B, C, and D are incorrect because the focus in this scenario is on proper handling and disposal of soiled linens to prevent the spread of infection, not on serving meals, psychological effects of isolation, or the use of paper trays and plastic utensils.
5. Which of the following statements by a client indicates adequate preparation for magnetic resonance imaging?
- A. "I should wear earplugs during the test."?
- B. "I should remove my metal jewelry before the test."?
- C. "I should inform the healthcare provider about my pacemaker."?
- D. "I should inform the healthcare provider about my artificial hip."?
Correct answer: A
Rationale: The correct statement is, '"I should wear earplugs during the test,"?' as MRI scanners produce loud noises requiring ear protection. Metal objects, including jewelry, are not allowed inside the MRI room due to safety concerns related to the magnetic field. Choices B, C, and D are incorrect. Choice B is wrong because metal objects, including jewelry, are not permitted in the MRI room. Choices C and D are incorrect as having a pacemaker or an artificial hip raises concerns due to the magnetic field in MRI, requiring special precautions or considerations. It is crucial for individuals with such implants to inform their healthcare provider to assess the risks and determine the appropriate course of action.
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