NCLEX-PN
NCLEX PN Test Bank
1. Which of the following microorganisms are considered normal body flora?
- A. staphylococcus on the skin
- B. streptococcus in the nares
- C. candida albicans in the vagina
- D. pseudomonas in the blood
Correct answer: A
Rationale: Staphylococcus is considered normal body flora as it is commonly found on the skin, being a part of the normal microbiota. While streptococcus in the nares can be part of the normal flora of the upper respiratory tract, it is not as common or as widespread as staphylococcus on the skin. Candida albicans in the vagina is not considered normal flora; it is a common opportunistic pathogen in the vagina. Pseudomonas in the blood is also not considered normal body flora; pseudomonas is not typically found in the blood as part of the normal microbiota.
2. A nurse on the night shift is making client rounds. When the nurse checks a client who is 97 years old and has successfully been treated for heart failure, he notes that the client is not breathing. If the client does not have a do-not-resuscitate (DNR) order, the nurse should take which action?
- A. Administer cardiopulmonary resuscitation (CPR)
- B. Call the client's health care provider
- C. Administer oxygen to the client and call the health care provider
- D. Contact the nursing supervisor for directions
Correct answer: A
Rationale: Administering cardiopulmonary resuscitation (CPR) is the appropriate action when a client is not breathing and does not have a do-not-resuscitate (DNR) order. CPR is considered an emergency treatment that can be provided without client consent in life-threatening situations. Calling the health care provider or nursing supervisor for directions, as well as administering oxygen without addressing the lack of breathing, would delay critical life-saving interventions. Therefore, administering CPR is the most urgent and necessary action to perform in this scenario.
3. What is the 24-hour day-night cycle known as?
- A. circadian rhythm
- B. infradian rhythm
- C. ultradian rhythm
- D. non-REM rhythm
Correct answer: A
Rationale: The correct answer is circadian rhythm. Circadian rhythm refers to the rhythmic repetition of patterns that occur approximately every 24 hours, regulating various biological processes related to the day-night cycle. Infradian rhythm, which is longer than 24 hours, and ultradian rhythm, which is shorter than 24 hours, are not the correct terms for the 24-hour cycle. Non-REM rhythm does not specifically relate to the 24-hour day-night cycle, making it an incorrect choice.
4. The physician's role in case management includes all of the following except:
- A. participating in interdisciplinary planning for clients.
- B. serving as the expert for resource utilization.
- C. consulting with the case management team to facilitate timely orders as needed.
- D. contributing to the documentation of a client's needs for services.
Correct answer: B
Rationale: The correct answer is 'serving as the expert for resource utilization.' While physicians play a crucial role in case management, their primary focus is on medical diagnosis and treatment rather than resource utilization. Choices A, C, and D are all roles that physicians typically fulfill in case management. A physician participating in interdisciplinary planning for clients ensures comprehensive care, consulting with the case management team helps in coordinating timely orders, and contributing to the documentation of a client's needs for services aids in providing appropriate care. Therefore, serving as the expert for resource utilization does not align with the primary responsibilities of a physician in case management.
5. The graduate licensed practical nurse is assigned to care for the client on ventilator support, pending organ donation. Which goal should receive priority?
- A. Maintain the client's systolic blood pressure at 70mmHg or greater
- B. Maintain the client's urinary output greater than 300cc per hour
- C. Maintain the client's body temperature above 33�F rectal
- D. Maintain the client's hematocrit below 30%
Correct answer: A
Rationale: When caring for a client on ventilator support pending organ donation, maintaining the systolic blood pressure at 70mmHg or greater is crucial to ensure a proper blood supply to the donor organ. This goal is a priority to maintain the viability of the organ for donation. Choices B, C, and D are incorrect because they are unnecessary and not directly related to the immediate goal of organ donation. Maintaining urinary output, body temperature, or hematocrit levels are not the primary concerns in this situation.
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