NCLEX-PN Test #13 2 — Questions and Answers
Question 1: The PN is assigned to four clients. Using Maslow's hierarchy, which client should be assessed first?
- A client with severe anxiety requesting to see a chaplain
- A client with heart failure awaiting discharge instructions
- A client post-op who just arrived to the floor with SpO₂ of 89% (Correct answer)
- A client with a surgical wound requesting a dressing change
Correct answer: A client post-op who just arrived to the floor with SpO₂ of 89%
Using Maslow's hierarchy, physiological needs take priority over all others. SpO₂ of 89% represents inadequate oxygenation — the most basic physiological need. This client must be assessed first as hypoxia can cause rapid deterioration. The other clients have needs that are important but not immediately life-threatening.
Question 2: A client asks the PN a question about surgery that goes beyond the scope of nursing practice. What is the most appropriate response?
- Provide the best answer the nurse can from memory
- Tell the client "That's not really my area — ask someone else"
- Acknowledge the question and communicate it to the surgeon for a proper response (Correct answer)
- Ask a more experienced nurse to answer on your behalf
Correct answer: Acknowledge the question and communicate it to the surgeon for a proper response
When a client's question exceeds the nurse's scope or expertise, the appropriate action is to acknowledge the question, avoid guessing or providing potentially incorrect information, and ensure the question is relayed to the appropriate provider (surgeon, physician) who can give an accurate answer. This protects the client and maintains professional boundaries.
Question 3: A client with end-stage cancer tells the nurse, "I just want to go home and die peacefully." How should the nurse respond?
- "Let's focus on treatment options — it's not time to give up."
- "I understand. Let's talk about your wishes and what we can do to make that happen." (Correct answer)
- "You should discuss this with your family first before making any decisions."
- "I'll document your request and someone from administration will contact you."
Correct answer: "I understand. Let's talk about your wishes and what we can do to make that happen."
The therapeutic response respects the client's autonomy and right to make decisions about end-of-life care. Acknowledging the wish without judgment and exploring options (palliative care, hospice, advance directives) is the appropriate nursing approach. Redirecting to more treatment dismisses the client's expressed wishes and is not therapeutic.
Question 4: The PN receives a telephone report about a client being transferred from the ICU. Using SBAR format, what information is communicated under "Situation"?
- Relevant past medical history and medications
- Current vital signs, reason for transfer, and immediate needs (Correct answer)
- Background on what brought the client to the hospital
- Recommendations for the receiving nurse's plan of care
Correct answer: Current vital signs, reason for transfer, and immediate needs
SBAR structured communication: Situation = what is happening now (client name, location, reason for transfer, current status, and immediate needs). Background = medical history and relevant context. Assessment = clinical judgment about the problem. Recommendation = what action is needed. Clear SBAR communication prevents handoff errors.
Question 5: A client with chronic obstructive pulmonary disease (COPD) has an order for morphine 2 mg IV for pain. The nurse is aware of the client's condition but notes the pain is moderate-severe (7/10). What is the most appropriate action?
- Refuse to administer the opioid and document the refusal
- Administer the morphine as ordered, monitor respiratory rate and SpO₂ closely, and have naloxone available (Correct answer)
- Administer half the dose and increase if needed
- Request a change to a non-opioid analgesic before any administration
Correct answer: Administer the morphine as ordered, monitor respiratory rate and SpO₂ closely, and have naloxone available
Opioids are not absolutely contraindicated in COPD. Undertreated pain also impairs respiratory effort by limiting deep breathing. The nurse should administer the morphine as ordered while closely monitoring respiratory rate (hold if < 12/min), SpO₂, and level of consciousness. Naloxone should be readily available. The benefit-risk ratio is acceptable in this scenario.
Question 6: The nurse is caring for a confused elderly client who is attempting to remove an IV line. Which intervention is most appropriate and least restrictive?
- Apply bilateral wrist restraints to prevent IV removal
- Place a loose long-sleeved garment over the IV site and engage the client in a meaningful activity (Correct answer)
- Request a one-to-one sitter and place the client in a room with a window
- Administer a PRN sedative to keep the client calm
Correct answer: Place a loose long-sleeved garment over the IV site and engage the client in a meaningful activity
The least-restrictive intervention principle requires trying non-restraint alternatives first. Covering the IV with a long sleeve reduces visibility (out of sight, out of mind) while an activity redirects the client. Restraints are a last resort and can worsen agitation, cause injury, and lead to deconditioning. Document all alternatives tried before restraint use.
NCLEX-PN Test #13 2
The PN is assigned to four clients.
Using Maslow's hierarchy, which client should be assessed first?