NCLEX-PN
2024 Nclex Questions
1. While walking in the hallway of an acute care unit of the hospital, the nurse overhears the change of shift report. What should the nurse do?
- A. Make the charge nurse on the unit aware of the situation so that they can take the necessary steps to maintain the confidentiality of the information being reported.
- B. Disregard the information because it changes quickly on the acute care unit and is outdated within 2-3 hours anyway.
- C. Return to their own unit and not disclose that confidential information has been overheard.
- D. Ignore the situation.
Correct answer: A
Rationale: To protect the confidentiality of the information being reported, the nurse should make the charge nurse on the unit aware of the situation. This allows the charge nurse to take necessary steps to maintain confidentiality and ensure that the information is communicated in an appropriate and private manner. Disclosing the situation to the charge nurse is essential to address any breaches in confidentiality and uphold professional standards of privacy and ethics. Disregarding the information, returning to their own unit without disclosure, or ignoring the situation altogether would not address the breach of confidentiality and could lead to further issues regarding patient privacy and trust.
2. After group therapy, the female victim of intimate partner violence confides to the nurse that she does not feel in any immediate danger. Which of the following statements about victims of domestic violence is true?
- A. Victims of domestic violence are often the best predictors of their risk of harm.
- B. Victims of domestic violence often overestimate their safety risk.
- C. Victims of domestic violence are typically in a state of denial.
- D. Victims of domestic violence know that keeping peace with their partner is the best method of preventing another attack.
Correct answer: A
Rationale: Victims of domestic violence are often correct at predicting their risk of harm. It is crucial for the nurse to ensure that the client is expressing herself authentically and not downplaying any potential danger. While victims can be insightful about their risk, it's essential to involve proper authorities, such as the police, in situations of intimate partner violence to ensure safety and provide necessary support. Choice B is incorrect because victims may not necessarily overestimate their safety risk. Choice C is incorrect as not all victims are in a state of denial; some may recognize the dangers they face. Choice D is incorrect because victims may not believe that keeping peace with their partner is the best way to prevent future attacks, as each individual's situation and mindset vary.
3. The new mother asks why her baby has lost weight since he was born. The best explanation of the weight loss is:
- A. The baby is dehydrated due to polyuria.
- B. The baby is hypoglycemic due to lack of glucose.
- C. The baby is allergic to the formula the mother is giving him.
- D. The baby can lose up to 10% of weight due to meconium stool, loss of extracellular fluid, and initiation of breastfeeding.
Correct answer: D
Rationale: After birth, newborns can lose weight due to meconium stool, loss of extracellular fluid, and the initiation of breastfeeding. This weight loss is a normal and expected physiological process, and infants can lose up to 10% of their birth weight during this period. There is no indication of dehydration (polyuria), hypoglycemia (lack of glucose), or allergy to the formula as reasons for weight loss in newborns. Therefore, answers A, B, and C are incorrect. Answer D provides the most accurate explanation for the observed weight loss in the newborn.
4. When caring for a Native-American family, what does the nurse need to consider?
- A. The family may consist of extended family members beyond parents and children.
- B. Native Americans tend to value their heritage and traditions.
- C. Some Native Americans use herbs and psychologic treatments for illnesses.
- D. Health care practices vary among different tribes and individuals.
Correct answer: C
Rationale: When caring for a Native-American family, it is crucial to acknowledge and respect their cultural beliefs and practices. Choice A, while relevant, is not as specific as understanding the use of herbs and psychologic treatments in Native American healing practices. Choice B, though generally true, does not directly impact the nursing care provided. Choice D, although true, is too broad and does not focus on the specific aspect of treatment practices. Choice C is the most appropriate answer as it highlights the importance of recognizing and incorporating traditional healing methods into the nursing care plan, promoting culturally sensitive and holistic care.
5. The mother of a newborn child is very upset. The child has a cleft lip and palate. The type of crisis this mother is experiencing is:
- A. reactive.
- B. maturational.
- C. situational.
- D. adventitious.
Correct answer: C
Rationale: The mother is experiencing a situational crisis as the unexpected birth of a child with a cleft lip and palate has placed her in a challenging situation she did not anticipate. This type of crisis is triggered by specific events and circumstances. Choice A, reactive, implies responding to a stressor after it has occurred, which is not the case here. Choice B, maturational, refers to stress related to developmental stages, not to external events like the child's condition. Choice D, adventitious, involves crises resulting from events outside one's control, such as natural disasters, which do not apply in this scenario.
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