Nclexpn
Practice Test 9 for Nclexpn: real questions and explanations from the Varsity Tutors practice-test pool.
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The PN is reinforcing dietary instructions for a client scheduled to collect three stool specimens at home for guaiac (occult blood) testing. Which statement by the client indicates a need for further teaching?
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The PN is reinforcing dietary instructions for a client scheduled to collect three stool specimens at home for guaiac (occult blood) testing. Which statement by the client indicates a need for further teaching?
Explanation: Certain foods can interfere with guaiac test results. While red meat can cause a false positive, certain raw vegetables high in peroxidase, such as turnips, broccoli, and radishes, can also cause a false-positive result and should be avoided. Avoiding red meat and vitamin C (which can cause a false negative) are correct instructions.
The LPN/VN understands that the legal and ethical requirement for informed consent is most fundamentally rooted in which bioethical principle?
Explanation: Informed consent is fundamentally grounded in the ethical principle of autonomy, which recognizes the right of competent individuals to make free, informed decisions about their own health care, including the right to accept or refuse treatment. Autonomy underlies the legal requirement that providers must disclose information, ensure comprehension, and obtain voluntary agreement before proceeding with treatment. Beneficence refers to promoting the client's best interest and provides the rationale for offering treatment, but it does not override autonomy when the client makes an informed choice. Non-maleficence is the duty to avoid harm and informs the requirement for risk disclosure but is not the primary basis of the consent requirement. Justice concerns fair resource distribution and is not the foundational principle for consent.
A practical nurse (PN) is reinforcing teaching about nutrition to a client at 10 weeks gestation. Which statement by the client indicates an understanding of the teaching?
Explanation: The correct statement indicates an understanding of the importance of folic acid in preventing neural tube defects in the developing fetus. Doubling caloric intake is a common misconception and can lead to excessive weight gain. Prenatal vitamins are necessary to supplement a balanced diet and ensure adequate micronutrient levels. Avoiding dairy is unnecessary unless the client has a lactose intolerance and could lead to inadequate calcium intake.
The healthcare provider needs to obtain telephone consent for an emergency procedure for a client who is confused. The client's designated healthcare proxy is on the phone. According to typical hospital policy, which action is required?
Explanation: Standard procedure for telephone consent requires two licensed healthcare professionals to listen to the verbal consent given by the authorized person. Both individuals then sign the consent form, documenting that consent was obtained via telephone. This ensures verification. Requiring the person to come to the hospital (A) could cause a dangerous delay in an emergency. Recording the call (C) is not standard practice and has privacy implications. The provider's word alone (D) is insufficient without proper witnessing and documentation.
A 73-year-old client in a long-term care facility has limited mobility and requires turning. Assessment: T 98.1°F (36.7°C), HR 86, RR 18, BP 130/72, pain 3/10; the client has fragile skin and bruises easily. Which positioning technique is MOST appropriate for preventing skin injury during repositioning?
Explanation: This question tests knowledge of mobility, positioning, and range of motion interventions. The priority concern is fragile skin and easy bruising during repositioning in a limited-mobility client. Using a friction-reducing sheet or drawsheet and lifting the client when moving up in bed is the best choice for safety and effectiveness as it prevents shear and trauma. Dragging (A) causes friction; massaging prominences (C) risks bruising; prolonged positioning (D) increases ulcer risk. A key decision-making principle is to lift rather than slide for skin protection. Another principle is to use team assistance for heavy clients. A transferable strategy is to employ low-friction aids routinely, inspecting skin post-repositioning to safeguard vulnerable clients.
The PN receives a container from a client for a sputum culture. The specimen is watery, thin, and clear. What is the PN's most appropriate action?
Explanation: A thin, watery, and clear specimen is most likely saliva, not sputum from the lower respiratory tract. Sending saliva to the lab for a sputum culture will yield inaccurate results. The PN should recognize the inadequate specimen, provide further instruction to the client on how to produce a deep cough to bring up sputum, and request a new sample. Documenting it as sputum or altering the specimen is incorrect.
A 74-year-old client with dementia is in a medical-surgical room with an indwelling urinary catheter for strict output monitoring. The client repeatedly attempts to pull out the catheter; the nurse has tried distraction, covering the tubing, and offering fluids and toileting, but the behavior continues. The nurse should QUESTION which restraint order given the client's situation?
Explanation: This question tests understanding of least restrictive restraints and monitoring in clients attempting to remove medical devices. The priority is maintaining client safety with dignity by questioning orders that do not align with minimal restriction principles. An order for bilateral wrist restraints to be used continuously without time limits until discharge should be questioned as it violates time-limited and least restrictive standards. Using mitts conditionally (B), increasing observation (C), or reassessing device need (D) better promote minimal intervention. The decision-making principle is that restraint orders must be specific, time-bound, and based on failed alternatives. Continuous restraints risk complications like skin breakdown. A strategy for evaluating restraint needs is to review orders for compliance with facility policy and ethical guidelines.
The nurse is monitoring a client receiving IV fluids at 125 mL/hr. Which finding suggests fluid volume overload and requires immediate reporting to the RN?
Explanation: Crackles (rales) heard upon auscultation of the lungs are a sign of fluid in the alveoli (pulmonary edema), which is a serious complication of fluid volume overload. This is an abnormal finding that indicates the client's circulatory system is overwhelmed and requires immediate intervention. The other findings are within normal limits or suggest dehydration.
A 38-year-old client at a walk-in clinic asks, “Can my spouse access my online patient portal?” The spouse is not present, and the client has a history of hypertension. The nurse should reinforce which aspect of privacy with the client?
Explanation: This question tests understanding of confidentiality and privacy in nursing practice. It relates to the legal framework of the Health Insurance Portability and Accountability Act (HIPAA) and ethical standards in nursing that protect patient information. The correct answer, portal access controlled by client's credentials or proxy, best protects client confidentiality by requiring authorization. Option A assumes spousal rights incorrectly, C allows improper sharing, and D misclassifies portal data. The decision-making principle is to let clients manage access. Nurses must explain setup processes. A transferable strategy is to assist with proxy designations during visits.
The LPN/VN receives handoff on 3 clients in an outpatient clinic under RN supervision. Client 1: 6-year-old with asthma, audible wheeze, using accessory muscles, SpO2 89% on room air, RR 34/min. Client 2: 30-year-old with a urinary tract infection, dysuria, afebrile, BP 122/78 mm Hg. Client 3: 52-year-old with hypertension here for routine blood pressure check, BP 168/94 mm Hg, no symptoms. Which client should the LPN/VN attend to FIRST under RN supervision?
Explanation: This question tests organizing and prioritizing client care in an outpatient setting using the ABC framework. The prioritization is based on immediate threats to airway and breathing. Client 1, the child with asthma showing SpO2 89%, accessory muscle use, and tachypnea (34/min), represents the highest priority because these indicate severe respiratory distress requiring immediate intervention to prevent respiratory failure. Client 2's UTI symptoms are uncomfortable but not life-threatening and can be treated after stabilizing the child, while Client 3's elevated blood pressure without symptoms can be addressed through routine management after emergent issues are resolved. The principle for pediatric prioritization is that children can decompensate rapidly, and respiratory distress with hypoxemia requires immediate intervention. When triaging multiple clients, always address airway and breathing emergencies first, particularly in pediatric clients who have less physiologic reserve.
A 72-year-old client is scheduled for a transurethral resection of the prostate (TURP) this afternoon. History includes benign prostatic hyperplasia and atrial fibrillation; medications include warfarin and tamsulosin. Labs: INR 3.6, Hgb 13.2 g/dL; vital signs stable. Which pre-procedure preparation is MOST important?
Explanation: This question tests clinical judgment in pre-procedure care for a client scheduled for TURP. The priority concern is the elevated INR of 3.6, which increases bleeding risk during surgery for a client on warfarin. Notifying the RN/provider about the elevated INR before surgery is the best choice for safe and effective care as it allows for potential reversal or delay to minimize hemorrhage risk. Compression stockings (A) and incentive spirometer teaching (C) are routine but not urgent; signing consent in pre-op (D) is standard but secondary to lab abnormalities. The nursing principle involved is assessing coagulation status preoperatively in anticoagulated clients. Guidelines from the American College of Surgeons emphasize correcting coagulopathy before invasive procedures. A transferable strategy for similar scenarios is to review and report critical lab values that impact procedural safety before transport.
The nurse is observing a group of toddlers in a daycare setting. Which type of play is most characteristic of 2-year-olds?
Explanation: Parallel play, where children play alongside each other but not with each other, is the predominant type of play for toddlers. Cooperative play, which involves organization and rules, is typical of school-aged children. Solitary play is more common in infancy. Competitive play is characteristic of older, school-aged children and adolescents.
A 72-year-old resident in a long-term care facility has early Parkinson disease and is discussing end-of-life preferences with family. The resident states they have a living will but are unsure what the durable power of attorney for health care (DPOA-HC) allows. The resident's nephew says, "I can make decisions because I'm family." The nurse should clarify which aspect of the advance directives with the client?
Explanation: This question tests understanding of advance directives clarification in coordinated care. Verifying and educating about advance directives requires clarifying misconceptions about who has decision-making authority and when these documents take effect. The correct answer (A) aligns with LPN/VN roles by explaining that the DPOA-HC specifically names the chosen decision-maker and that family relationship alone doesn't grant this authority, which respects client autonomy and corrects the nephew's misunderstanding. Option B incorrectly describes living will function; Option C falsely requires court hearings; Option D incorrectly states that living wills cannot be changed. Clear communication helps prevent family conflicts and ensures the client's chosen representative is recognized. A strategy for accuracy is to explain that only the person named in the DPOA-HC document has legal authority to make healthcare decisions when the client cannot.
An 86-year-old client with a stroke is chairbound and requires a mechanical lift for transfers. Skin assessment reveals blanchable redness over the sacrum and moisture from urinary incontinence. Braden Scale score is 10. Current interventions include repositioning every 3 hours and a disposable brief. Which assessment finding indicates a risk for pressure injury?
Explanation: This question tests understanding of skin integrity and pressure injury prevention by identifying moisture as a risk factor. The priority framework for preventing pressure injuries includes assessing for extrinsic factors like moisture. Moist, macerated skin in the perineal area from incontinence indicates the best choice as it heightens breakdown risk in this high-risk client. Warm skin temperature is normal; a small bruise may not relate; hair growth is unrelated. The evidence-based principle of pressure injury prevention addresses incontinence to protect skin barrier. A transferable strategy for maintaining skin integrity is to use absorbent briefs with frequent changes. Proactive assessment and intervention are essential to manage blanchable redness and moisture.
The nurse is reinforcing teaching for a client with type 1 diabetes about subcutaneous insulin injection sites. Which statement by the client indicates a need for further teaching?
Explanation: Injecting insulin into a limb that will be heavily exercised can cause the insulin to absorb more rapidly than usual, potentially leading to hypoglycemia. The client should be taught to avoid injecting into a muscle group that will be used extensively during exercise. The other statements demonstrate a correct understanding of insulin administration.
The LPN is caring for a client with type 1 diabetes mellitus who is scheduled to receive a dose of regular insulin. The client is diaphoretic and reports feeling shaky.
What is the priority data for the LPN to collect and report before administering the insulin?
Explanation: The client's symptoms (diaphoresis, shakiness) are classic signs of hypoglycemia. Administering insulin to a hypoglycemic client can be fatal. The priority action is to check the capillary blood glucose level to confirm hypoglycemia and report the finding before any insulin is given. The other data points are relevant but not the immediate priority.
A 82-year-old client with chronic heart failure takes furosemide and carvedilol; today the client reports swelling in ankles but denies shortness of breath at rest. Assessment: heart rate 76/min, respiratory rate 18/min, blood pressure 118/70 mm Hg, oxygen saturation 95% on room air; 1+ ankle edema; weight up 1 lb (0.45 kg) since last week; labs: potassium 2.9 mEq/L. Which data indicates an acute change that requires IMMEDIATE action?
Explanation: This question tests the recognition of acute versus chronic illness in a client with chronic heart failure. The key assessment data indicating an acute change is potassium level of 2.9 mEq/L while taking a loop diuretic, despite minimal weight gain and edema. This reflects an immediate concern because hypokalemia can lead to arrhythmias and requires prompt correction in heart failure. The 1+ ankle edema (B), oxygen saturation of 95% (C), and history of carvedilol use (D) are less critical as they represent mild chronic fluid retention, normal oxygenation, and standard pharmacologic management. A key nursing concept is monitoring electrolytes to prevent acute imbalances from chronic diuretic therapy. Regular lab checks help differentiate acute risks from stable chronic symptoms. A transferable strategy is to review electrolyte levels in clients on diuretics to identify acute changes in chronic conditions.
The nurse is reinforcing teaching with a 50-year-old female client about breast health and the importance of clinical breast examinations.
Which statement by the client indicates a correct understanding of current health promotion guidelines?
Explanation: For women aged 40 and older, an annual clinical breast exam performed by a healthcare provider is a standard component of breast health promotion. The clinical exam complements mammography by providing physical palpation of breast tissue and regional lymph nodes and allows the provider to address questions and reinforce self-awareness. Waiting for a self-discovered lump (A) delays detection of non-palpable or subtle changes that a trained provider might identify earlier. Clinical breast exams and mammography serve different purposes and are not mutually exclusive (C). Daily self-examination (D) is excessive — monthly breast self-awareness is the recommended frequency, allowing the woman to establish a baseline rather than detecting normal cyclic changes that vary daily with hormonal shifts.
A 58-year-old client with chronic obstructive pulmonary disease is being discharged home with new home oxygen at 2 liters per minute via nasal cannula and a rescue inhaler. The client is stable, has oxygen saturation 92% on 2 liters, and lives with a spouse; the LPN/VN is coordinating with the respiratory therapist, home health agency, and the RN to ensure safe discharge. Which action by the nurse ensures continuity of care?
Explanation: This question tests skills in discharge and transfer participation within coordinated care for a client requiring home oxygen therapy. The priority concern is ensuring safe oxygen use and continuity of respiratory care in the home setting. Confirming equipment delivery and communicating flow rate and safety precautions to home health ensures the client has necessary equipment and support for safe oxygen use at discharge. Telling the client to adjust oxygen independently (B) is dangerous as it can lead to CO2 retention; advising that smoking is acceptable with oxygen off (C) is unsafe as oxygen saturates clothing and surroundings; and stopping the rescue inhaler (D) removes an important treatment component. The decision-making principle is that discharge coordination must include verification of equipment, clear communication with all providers, and reinforcement of safety measures. A transferable strategy is to use a discharge checklist that includes equipment verification, provider communication, and safety education confirmation before releasing a client requiring medical equipment.
Setting: Post-operative recovery unit. Client: 65-year-old male, Post-operative Day 1 after a major cardiac procedure. 0900 Situation: The nurse enters the room and finds the client slumped over in the bedside chair. He does not respond to his name or a gentle shake. 0902 Assessment: The client has no palpable carotid pulse and is not breathing. The skin is cool and mottled.
Which intervention should the nurse immediately implement as part of the facility's emergency response?
Explanation: Simultaneous activation of the emergency response system (Code Blue) and initiation of chest compressions is the correct first response to confirmed cardiac arrest. Every second without circulation is irreversible brain injury. Regarding Choice D: the correct principle is that resuscitation is initiated unless a valid DNR order is immediately known and available. If the DNR status is unknown at the moment of the arrest — as in this scenario — CPR must begin immediately while a second responder searches for the documentation. Stopping to check the EHR before starting compressions could cost 2 to 3 minutes of critical resuscitation time. Repositioning the client (A) does not address the cardiac arrest and delays necessary intervention. Seeking family consensus (B) bypasses established legal protocols for advance directives and delays care.
The nurse is assessing a client who has a nasogastric (NG) tube for enteral feeding. The nurse notes the client has developed a new, frequent cough and has a decreased oxygen saturation level.
The nurse should recognize these findings as potential indicators of:
Explanation: A new, frequent cough and decreasing oxygen saturation in a client receiving NG tube feedings are critical warning signs of pulmonary aspiration — entry of feeding formula into the tracheobronchial tree. Aspiration can cause aspiration pneumonia, which is a serious, potentially fatal complication. The nurse must immediately stop the feeding, position the client upright, suction the airway if needed, notify the PHCP, and prepare for further evaluation including chest X-ray. A new, frequent cough is not an expected response to an NG tube (B) — while mild, occasional throat clearing can occur, a frequent productive cough with falling SpO2 is abnormal and clinically significant. A nasal infection (C) would produce localized nasal symptoms (discharge, tenderness) but not new cough and oxygen desaturation. Formula concentration (D) has no relationship to cough or oxygenation status.
A 45-year-old client is hospitalized after a motor vehicle crash and is receiving pain medication. A local reporter calls the unit and asks if the client is admitted and what injuries the client has. The facility has a strict privacy policy and does not release any information without authorization. Which action should the nurse take to maintain client confidentiality?
Explanation: This question tests ethical practice within the scope of the LPN/VN, focusing on confidentiality in media inquiries. The legal standard is facility privacy policy and HIPAA, prohibiting release of information without authorization, especially to non-authorized parties like reporters. Option B is the most ethical as it neither confirms nor denies information, referring to a spokesperson to maintain strict privacy. Option A confirms admission, breaching policy; C shares condition vaguely but still violates; D involves the provider inappropriately. The framework requires recognizing unauthorized requests, avoiding any disclosure, and following protocol for external communications. Document the interaction and report to supervisors for compliance. A transferable strategy is to use neutral responses in privacy queries and advocate for client rights to ensure ethical integrity.
A 66-year-old client on a medical unit has an advance directive requesting comfort-focused care only if the condition worsens. The client is now alert and tells the nurse, "I changed my mind; I want all treatments," but the written document has not been updated. Facility policy requires the nurse to report changes in wishes to the provider and document the client's statements. Which action aligns with respecting the client's advance directives?
Explanation: This question tests ethical practice within the scope of the LPN/VN, concerning changes in advance directives. The legal standard allows alert clients to update wishes, requiring notification and documentation for review. Option B is the most ethical as it notifies the provider of changes and documents, facilitating plan updates. Option A dismisses verbal changes; C involves family; D bypasses procedure. The framework assesses capacity, reports changes, and follows policy. Ensure interdisciplinary involvement. A transferable strategy is to document verbal updates and escalate, supporting ethical flexibility in client decisions.
The practical nurse (PN) is observing the skin around a client's mature gastrostomy tube (G-tube) stoma. Which finding requires the PN to intervene and notify the RN?
Explanation: Redness, swelling, and purulent drainage are classic signs of a site infection, which must be reported to the RN and healthcare provider for further evaluation and treatment. The ability to rotate the tube, the bumper resting on the skin, and a small amount of clear or serous drainage are normal findings for a mature G-tube site.
A 59-year-old client is prescribed warfarin 7.5 mg PO daily. The available tablets are 5 mg. How many tablets should the client receive per dose?
Explanation: This question tests medication dosage calculation skills. The key calculation principle is dose conversion to number of tablets, including fractions. The correct answer of 1.5 tablets is calculated by dividing 7.5 mg by 5 mg (7.5 / 5 = 1.5). Choice A (1 tablet) results from rounding down; choice C (2 tablets) from rounding up; choice D (0.75 tablet) from halving. The formula used is number of tablets = ordered / available. Check if scored. A transferable strategy is to divide directly and verify if partial tablets are allowable.