NCLEX-PN Test #14 2

Question 1

The PN is preparing to transfer a client from the bed to a wheelchair. The client weighs 200 lbs (91 kg) and has one-sided weakness. Which action ensures the safest transfer?

Accepted Answer

Position the wheelchair on the client's stronger side and lock the wheels before transfer

Answer

Positioning the wheelchair on the strong side allows the client to lead with the strong leg and pivot more safely. Locking wheels before transfer prevents the chair from sliding. For clients with one-sided weakness (hemiplegia), the strong side is used for stability. The gait belt provides additional safety for the nurse.

Question 2

A nurse receives a call from a person claiming to be the client's physician, requesting the client's HIV status over the phone. What is the correct response?

Accepted Answer

Inform the caller that HIV status is protected health information that requires identity verification per policy before disclosure

Answer

HIV status is specially protected health information under both HIPAA and most state laws. Identity cannot be verified over the phone. The nurse must follow facility policy, which typically requires the provider to access information through authenticated EHR access. Verbal disclosure over phone to an unverified caller violates confidentiality.

Question 3

A nurse discovers a small fire in the client's room. Using the RACE protocol, what is the correct sequence?

Accepted Answer

Rescue — Alarm — Contain — Extinguish

Answer

RACE fire response protocol: R — Rescue (remove persons in immediate danger), A — Alarm (activate fire alarm, call 911), C — Contain (close doors to limit spread), E — Extinguish (use fire extinguisher only if safe to do so). Client safety is the absolute priority before any other action.

Question 4

The nurse is reviewing a client's medication administration record and notes the client received the wrong dose of insulin 30 minutes ago. What is the priority action?

Accepted Answer

Immediately assess the client, notify the provider, and complete an incident report

Answer

After a medication error, priorities are: (1) assess the client for adverse effects (hypoglycemia from excess insulin), (2) notify the provider immediately for orders to monitor and treat, (3) complete an incident report per facility policy, and (4) document the client's condition and actions taken in the medical record. Patient safety first, then reporting.

Question 5

The PN is caring for a client with a latex allergy. Which item commonly found in the clinical environment may contain latex?

Accepted Answer

Tourniquets, some IV tubing, and stethoscope tubing

Answer

Latex is found in many clinical items: rubber gloves, blood pressure cuffs, tourniquets, IV tubing injection ports, catheter balloons, stethoscope tubing, and tape backings. A latex-safe environment requires latex-free substitutes for all equipment. Cross-reactivity foods include bananas, avocados, kiwi, and chestnuts.

NCLEX Practice Test

NCLEX Practice Test

NCLEX-PN Test #14 2