NCLEX PN Practice Questions
Question 1 of 5.
The nurse is observing client care situations. Which of the following situations would require an order for physical restraints? Select all that apply.
A. A long leg immobilizer is used for a client with a fractured tibia.
B. A mummy restraint is used for an infant while the nurse obtains a blood specimen.
C. Full padded side rails are placed in the raised position for a client who is experiencing a seizure.
D. A belt restraint is used for a client with confusion who is on bed rest but continually attempts to get out of the bed.
E. A soft ankle restraint is used to prevent bleeding at the femoral site for a client who had a cardiac catheterization and is drowsy.
Explanation: Belt and ankle restraints require a provider's order due to their restrictive nature. Immobilizers, mummy restraints, and padded rails are typically used for specific purposes without restraint orders.
Question 2 of 5.
The nurse is caring for a woman who is admitted for a hysterectomy. The woman does not speak English. No staff members speak the client's language. Which approach by the nurse would be most appropriate when communicating with the client about her care before and after the surgery?
A. Ask the woman's 8-year-old daughter who speaks English to interpret.
B. Draw pictures and gesture when speaking to the client.
C. Speak very slowly when giving the client instructions.
D. Request an interpreter from social services.
Explanation: The nurse should request an interpreter from social services to ensure accurate communication. Using a child to interpret is inappropriate due to medical terminology and privacy concerns. Pictures, gestures, or slow speech in English are insufficient for surgical care discussions.
Question 3 of 5.
The nurse is caring for a client who has been in alcohol detoxification for one week. The client has slurred speech and is bumping into doorframes and walking unsteadily. What is the most appropriate initial action by the nurse?
A. Assess for Wernicke-Korsakoff syndrome
B. Ask for an order for blood alcohol level
C. Request a neurology consult
D. Administer a PRN dose of diazepam (Valium)
Explanation: Slurred speech and unsteady gait post-detox may indicate Wernicke-Korsakoff syndrome, a thiamine deficiency complication, requiring urgent assessment.
Question 4 of 5.
An adult who is scheduled for surgery tomorrow asks the nurse to arrange for his Healing Touch practitioner to give him healing touch treatments after surgery. The client's daughter who hears the request asks the nurse to explain how Healing Touch can help her father. What information should the nurse include in the response?
A. Healing Touch makes use of the power of suggestion and can help the person feel more comfortable.
B. No one really knows how it works, but if a person really wants it, it certainly will not hurt.
C. The Healing Touch practitioner works within the energy field around the person to facilitate healing and pain relief.
D. Healing Touch is similar to acupuncture except that pressure is used instead of needles.
Explanation: Healing Touch involves manipulating the energy field to promote healing and pain relief, a recognized complementary therapy.
Question 5 of 5.
An adult is hospitalized following a myocardial infarction. While the client is receiving heparin, the nurse should have which of the following medications available?
A. Aspirin
B. Calcium gluconate
C. Vitamin K
D. Protamine sulfate
Explanation: Protamine sulfate is the antidote for heparin overdose, reversing its anticoagulant effects in case of bleeding.
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