NCLEX-PN Practice Exam 10

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The nurse should understand regulations of nursing practice as put forth by the Nurse Practice Act. Identify the statement which is incorrect.

Correct! Wrong!

The Nurse Practice Act is a series of statutes enacted by the federal government in order to regulate the practice of nursing. The Nurse Practice Act is a series of statutes enacted by each state legislature in order to regulate the practice of nursing in that particular state. All the other statements are true and correct.

The Boards of Nursing have the right to revoke, deny, or suspend any license to practice as a practical/vocational nurse within their jurisdiction. There are several causes or actions which are considered to be causes for disciplinary action by the Board of Nursing. Identify the cause for disciplinary action which is incorrect.

Correct! Wrong!

Informing your supervisor that you cannot assume nursing duties until sufficient preparation for the specific duty has been provided. It is the nurse’s responsibility to inform the supervisor of an inappropriate assignment. The nurse should let the supervisor know that they are uncomfortable performing these duties until they have been prepared to handle them. The supervisor may then make a more appropriate assignment. All the other statements are correct and are reasons for the Board of Nursing to take disciplinary action towards the nurse.

A nurse is planning assignments for the upcoming shift. Which of the following would be the most appropriate assignment for the nursing assistant?

Correct! Wrong!

Assist a diabetic client on bedrest with a bed bath. This would be the MOST appropriate assignment to give to the nursing assistant with the information which has been provided. It would be inappropriate for the nursing assistant to record the vital signs in the medical chart. Since the patient requiring feeding had a stroke three days earlier, there is a greater risk of choking and/or aspiration of food material. The Alzheimer’s patient may be confused and may have the potential for difficulties in regards to bathroom assistance.

Vitamin K is typically given during the immediate post delivery period to the healthy newborn infant. The IM injection is administered in the vastus lateralis muscle of the infant’s thigh. What is the MOST appropriate response for the nurse to give if questioned by the parents about the reason for the injection?

Correct! Wrong!

“This is a Vitamin K injection. Infants are deficient in Vitamin K for the first 5- 8 days of life. Vitamin K helps their blood clot. This injection is administered to all healthy newborns to help their blood clot better.” Telling the parents that the injection is for their child’s own good is an unprofessional explanation. It is untrue that infants do not feel pain. They are able to feel pain and discomfort. Telling the parents that the injection is a “necessary evil” creates a negative view of the procedure and again an unprofessional explanation. This would not be the most appropriate answer. The last response is an example of the nurse assuming that the parents do not wish for their child to receive the injection. The parents simply asked for its purpose and an explanation of why it needed to be given.

A nurse has received orders to administer a RhoGAM injection IM to a postpartum patient. Which situation is NOT a contraindication for administration of this injection?

Correct! Wrong!

Administration of the injection within 72 hours after delivery. The injection is given to an Rh-negative mother to prevent isoimmunization from the possibility of exposure to Rh-positive blood. Exposure can occur not only through delivery of an Rh-positive infant but also by transfusion, amniocentesis, chorionic villus sampling, abdominal injury or trauma, bleeding during pregnancy, and termination of a pregnancy. The injection should never be administered to an Rh-positive patient, a patient with an elevated temperature, or a patient with a history of an allergic reaction to preparations containing human immunoglobulins. The injection should never be administered to a newborn.

A nursing student is asked by her nursing instructor to explain and give an example of Erik Erikson’s Identity vs. Role Confusion psychosocial development stage. The MOST appropriate answer would be:

Correct! Wrong!

"This stage occurs in adolescence (12-20 years), when the adolescent is confused about who he is. An example is when the adolescent obtains a tattoo, which he feels shows the world who he really is.” The school age child (6-12 years) is in the stage or psychosocial crisis of “industry vs. inferiority”. In early adulthood (20-35 years), they are experiencing the “intimacy vs. isolation” stage or crisis. In middle adulthood (35-65 years), they are experiencing the “generativity vs. stagnation” stage or crisis.

The nurse is assessing a multigravida, 36 weeks gestation for symptoms of pregnancy-induced hypertension and preeclampsia. The nurse should give priority to assessing the client for:

Correct! Wrong!

The nurse should pay close attention to swelling in the client with preeclampsia. Facial swelling indicates that the client’s condition is worsening and blood pressure will be increased. Answer B is not related to the question; therefore, it is incorrect. Answer C is incorrect because ankle edema is expected in pregnancy. Diminished reflexes are associated with the use of magnesium sulfate, which is the treatment of preeclampsia; therefore, answer D is incorrect.

An adolescent with borderline personality is hospitalized with suicidal ideation and self-mutilation. Which goal is both therapeutic and realistic for this client?

Correct! Wrong!

Verbalizing feelings of anger and sadness to a staff member is an appropriate therapeutic goal for the client with a risk of self-directed violence. Answers A and C place the client in an isolated situation to deal with her feelings alone; therefore, they are incorrect. Answer B is incorrect because it does not allow the client to ventilate her feelings.

A client with angina has an order for nitroglycerin ointment. Before applying the medication, the nurse should:

Correct! Wrong!

The nurse should remove any remaining ointment before applying the medication again. Answer A is incorrect because it interferes with absorption. Answer B does not apply to the question of how to administer the medication; therefore, it is incorrect. Answer D is incorrect because the medication’s action is more immediate.

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