NCLEX NCLEX Certifications NCLEX-PN Questions & Answers

• Question 591:

  The emergency triage nurse should perform which action upon receiving the history that a client has a severe cough, fever, night sweats, and body wasting?

  A. Place the client in the waiting room until an available cubicle is open.

  B. Seclude the client from other clients and visitors.

  C. Perform no intervention because it might not be necessary until tests confirm a disease.

  D. Don gown, gloves, and mask immediately.

  Correct Answer: B

  The client is describing signs and symptoms of tuberculosis. The client is potentially infectious to others and should be secluded. A respirator mask should be worn by caregivers, but it is not necessary for the nurse to don a gown and gloves. If the client is moved to other areas such as radiology, a mask should be worn by the client and a respirator mask should be worn by those working in close contact with the client.

• Question 592:

  The orientation nurse educator reviewing the biohazard legend with a class of new employees states that the emblem is affixed to containers whenever __________.

  A. there is presence of blood and body fluids

  B. there is the need for droplet precaution

  C. there is contact isolation

  D. there is the potential for airborne transmission

  Correct Answer: A

  When body substances are handled, the potential for transmission is increased; therefore, federal

  regulations require warning labels to communicate with other employees and/or waste collectors.

  The biohazard alert is a three-ring symbol overlaying a central concentric ring.

  Blood, drainagefrom wounds, feces, and urine are all body fluids that can transfer infection and disease to

  others.

• Question 593:

  The nurse is preparing to administer IV Vancomycin to a client. Which of the following nursing actions should be taken first?

  A. performing a physical assessment prior to administration

  B. obtaining the most recent lab values regarding renal function

  C. reviewing peaks and troughs for the past few days

  D. ensuring the client is not allergic to the medication

  Correct Answer: D

  Even before the physical assessment (which might or might not be indicated at the time of administration of Vancomycin), ensuring that the client is not allergic to the medication is the most critical action the nurse must take before administering any drug. Lab values regarding renal functioning and therapeutic ranges via peaks and troughs are also important with some medications such as Vancomycin because renal damage can occur if blood drug levels remain high over time.

• Question 594:

  Hearing screening of prematurely born infants is an effective means of identifying disease and is an example of __________.

  A. primary prevention

  B. secondary prevention

  C. tertiary prevention

  D. disability prevention

  Correct Answer: B

  The three levels of prevention address disease and disability across all phases, from absence of disease and at risk for disease, to preventing further impairment. Hearing impairment associated with prematurity cannot be prevented by screening, but identifying the infants with hearing loss might prevent sequelae and further impairment by allowing early intervention.

• Question 595:

  A community health nurse is asked to organize a health promotion project that plans to provide glucose screening.

  This activity is most beneficial within what realm?

  A. testing that is performed by volunteers at a local department store and is open to the public

  B. at a professional health fair activity available for selected persons who have been screened as being at risk

  C. mass-marketing vouchers for free fingersticks at a local drug store, where the pharmacist makes recommendations on the findings

  D. testing that is performed by a nurse professional, who immediately provides education regarding the findings

  Correct Answer: B

  Public glucose screening has been found to be an ineffective way to screen for diabetes unless based on health risk screening for those persons identified to be at risk or displaying symptoms.

• Question 596:

  The nurse's first action upon discovery of an electrical fire should be which of the following?

  A. Disconnect the electrical power if it can be performed safely.

  B. Smother the source with an object such as a blanket.

  C. Saturate the source with water or other readily available liquid.

  D. Activate the fire alarm immediately.

  Correct Answer: A

  If it is safe to do so, the nurse should disconnect electrical devices from the power source.

  Smothering with a blanket is not indicated in an electrical fire and might serve to fuel the fire, just as water

  or other liquids might incite an explosion or flames. The fire alarm should be activated promptly, and this

  should be the next action after disconnecting the electrically powered equipment.

• Question 597:

  A client has sustained a hyphema.

  What intervention should the nurse take?

  A. Have the client wear ear protectors in the future.

  B. Keep the client at bed rest, typically with the head of the bed propped up.

  C. Apply atropine eye drops.

  D. Apply an ice pack to the site of injury.

  Correct Answer: B

  Initial care of the client involves preventing further damage and rebleeding.

  Clients are kept at bed rest if possible, usually with the head of the bed raised. TV watching is permitted

  but not reading. The use of atropine, ice, and eye shields are controversial, and a nurse should not

  administer a pharmacologic agent or thermal therapy without a physician's order.

• Question 598:

  Acute hyphema is associated with what type of injury?

  A. orthopedic

  B. eye

  C. insect sting or snakebite

  D. gynecological trauma

  Correct Answer: B

  An acute hyphema occurs as a result of a blunt injury to the eye and is manifested by a half-moon appearance or a horizontal line across the globe when the client is upright (due to blood collected in the anterior chamber).

• Question 599:

  A risk management program within a hospital is responsible for all of the following except __________.

  A. identifying risks

  B. controlling financial loss due to malpractice claims

  C. making sure that staff follow their job descriptions

  D. analyzing risks and trends to guide further interventions or programs

  Correct Answer: C

  Risk management is an organizationwide program to identify risks and control incidents and legal liability. It does not have any direct supervisory or management responsibility for staff.

• Question 600:

  Regardless of their practice area, nurses should be concerned with __________.

  A. all drug-resistant bacteria

  B. microorganisms that are critical

  C. transmission of microorganisms

  D. overprescription of bacteriostatic drugs

  Correct Answer: C

  All nurses should be concerned with preventing the transmission of microorganisms to themselves as well

  as to others.

  One way to accomplish this goal is by asepsis.

  Nursing practice focuses on providing a safe and therapeutic environment to protect clients, family

  members, and health care providers from acquiring infections.