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NCLEX style questions PN Fundamentals
Final Review
When managing the care of a client, which of the following nursing actions is most appropriate to preform first? - ANSWER Assess the client physically According to most nurse practice acts, if a charge nurse assigns a LPN to admit a new client, what is the practical nurses primary role? - ANSWER gather basic information from the client At a team conference, staff members discuss a clients nursing diagnoses. Which one of the following nurse diagnoses is of highest priority? - ANSWER ineffective airway clearance The LPN notes that an expected outcome of bathing independently has not been reached by the target date. What action is most appropriate to take at this time? - ANSWER revise the interventions or target date for achieving the goal When gathering nursing date on a newly admitted client, which of the following is an appropriate source to consult for additional information? - ANSWER the clients family
Which practice could jeopardize the health agency's accreditation? - ANSWER nurse writes names of clients on dry erase board in public area Which example of poor documentation places the writer in the most legal jeopardy? - ANSWER writer squeezes information into a line written hours earlier Which method of documentation is used when the nurse charts only abnormal assessment findings or care that deviates from the agency's standard? - ANSWER charting by exception For which of the following situations is breaching confidentiality appropriate? - ANSWER client has a highly contagious disease When using the SOAP method of documentation, what does the "A" represent? - ANSWER analysis What is the minimum amount of time required for performing an alcohol-based hand rub? - ANSWER 15 seconds Which of the following are appropriate aseptic practices in relation to hand hygiene? - ANSWER the fingernails are less than 1/4 inch, the nurse removed all remnants of fingernail polish, rubs tips pf the fingers against the opposite palm containing an alcohol-based product
What is the most accurate instruction a nurse can provide before using a Snellen chart to assess a client's vision? - ANSWER read the letters standing at a distance of 20 feet Which of the following indicates that a client needs more teaching before a sigmoidoscopy? - ANSWER client says an anesthetic will be given before the examination Which nursing action is essential before performing a chest roentgenogram (X- ray)? - ANSWER remove clients metal necklace Which of the following instructions is most appropriate if a specimen for a Pap test will be obtained at the time of a pelvic examination? - ANSWER do not douche for several days before appointment Which of the following actions are correct when measuring a clients capillary blood glucose? - ANSWER wash hands, test strip matches, strip matches meter, cover strip completely When a nurse observes that a client with upper abdominal pain is curled in a fetal position and rocking back and forth, which action would help most to further assess the clients pain? - ANSWER ask client to rate pain form 0 to 10
What type of pain is a client with an amputated arm experiencing who states " I know my arm is not there, but I can feel it throbbing?" - ANSWER phantom pain A nurse can expect that acute pain may have which of the following effects on the clients vital signs? - ANSWER pulse rate may be rapid Which of the following is the best action for a hospice nurse to take to provide maximum pain relief when caring for a client with terminal cancer? - ANSWER administer pain medication every 3 hours as prescribed Which of the following categories of medications would be considered adjuvants?
- ANSWER antidepressants, anticonvulsants When a client returns from surgery, which sign is an early indication that the clients oxygenation status is compromised? - ANSWER client becomes restless If a client is adequately oxygenated, in what range should a pulse oximeter identify as the Sp02 measurement - ANSWER 95% to 100% When administering oxygen with a partial rebreather mask, which of the following observations is most important to report to the respiratory therapy department? - ANSWER reservoir bag collapses during inspiration
As the physician wraps the arm of a client with rolls of wet plaster, what is the most appropriate method the nurse should use for supporting the wet cast - ANSWER support wet cast with the palms of the hands Which one of the following is accurate when a nurse describes the advantage of fiberglass casts? - ANSWER generally more light weight Which of the following techniques is best for assessing circulation in the casted extremity of a client with a long leg plaster cast? - ANSWER depress the nail bed and time the return of color Which finding is most suggestive that a client in skeletal traction has an infection at the pin site? - ANSWER there is purulent drainage at the site While providing nursing care for a client in Buck's skin traction, which of the following indicates a need for immediate action? - ANSWER the clients foot is touching the end of the bed Assuming a client is admitted the evening before surgery, when is it best for the nurse to perform preoperative skin antisepsis and hair removal, if the latter is necessary on a client who is scheduled for a procedure at 1300? - ANSWER before transport to the receiving area
From whom is it most appropriate to obtain consent to perform surgery on an adolescent with a fractured tibia? - ANSWER clients parent If a client who will undergo surgery is wearing a ring which action is most correct?
- ANSWER lock the ring with his valuables What is the most important nursing action after giving a preoperative medication containing a narcotic? - ANSWER raise the side rails When the nurse assesses a client postoperatively, which assessment is most indicative of shock? - ANSWER low blood pressure Which of the following body positions will promote wound drainage from an abdominal incision with an open drain? - ANSWER Fowlers When the nurse changes a clients dresssing, which nursing action is correct? - ANSWER The nurse encloses the soiled dressing within latex drug When a nurse empties the drainage in a Jackson-Pratt reservoir, which nursing action is essential for reestablishing the negative pressure within this drainage device? - ANSWER the nurse compresses the bulb reservoir and closes the vent
