NCLEX-RN Sample Questions & Answers

The LPN scope of practice includes caring for stable clients with predictable outcomes. Administering routine medications like nebulizer treatments to a client with stable COPD falls within the LPN's scope. The other clients require the comprehensive assessment, planning, and teaching skills of an RN due to their instability (post-op), complex teaching needs (discharge), or need for IV push medications.

Primary prevention aims to prevent disease before it occurs. Teaching healthy lifestyle habits to children is a classic example of primary prevention for type 2 diabetes. Blood glucose screening is secondary prevention (early detection). Foot care clinics and medication management classes are tertiary prevention (managing existing disease).

Nurses are legally and ethically obligated to question any order that appears incorrect, unsafe, or unclear. A nurse who administers a medication based on an unsafe or illegible order is also liable for any harm that results. The nurse's duty is to clarify the order with the prescriber before administration.

The most therapeutic response is to acknowledge the feeling (fear) behind the delusion without reinforcing or challenging the delusion itself. This validates the client's experience while gently redirecting them to a reality-based activity and a safer-feeling environment. Directly challenging the delusion is ineffective and can increase agitation. Asking for more detail reinforces the delusional content. Asking why they believe it can also increase agitation.

Lack of tidaling (fluctuation) in the water-seal chamber can indicate either that the lung has re-expanded (a positive sign) or that there is an obstruction in the system (a negative sign). The priority action is to assess for the cause. This includes assessing the client's respiratory status (breath sounds) and checking the tubing for kinks or dependent loops. If breath sounds are diminished and the tubing is kinked, the nurse has identified a problem to correct. If breath sounds are clear and equal, it may indicate lung re-expansion, which can be confirmed with a chest x-ray. The other actions are premature or incorrect.

Reaching over a sterile field violates the principle that a sterile field must not be contaminated by non-sterile objects passing over it.

A sterile field should always be kept in view to ensure it remains sterile. Turning your back to the field is a break in technique.

A wet sterile field allows for capillary action, wicking microorganisms from the non-sterile surface below up to the sterile surface, thus contaminating it.

The most reliable indicator of adequate intake in a breastfed newborn is output. By day two, the infant should have at least two wet diapers. However, having three wet diapers and the progression from meconium to transitional stools is a stronger indicator of sufficient intake and gastrointestinal function. The duration of feeding is not a reliable indicator, and while soft breasts suggest milk transfer, output is the definitive measure. Two wet diapers and one meconium stool is the minimum expectation for day two, but three wet diapers and two transitional stools is a better indicator of adequate intake.

The client's symptoms (tremors, anxiety, diaphoresis, tachycardia) are classic signs of acute alcohol withdrawal, which typically begins 6-12 hours after the last drink. These symptoms reflect CNS hyperexcitability as the depressive effect of alcohol is removed.

Shortening of the affected leg with internal or external rotation are classic signs of hip prosthesis dislocation, which is a medical emergency. This finding requires immediate notification of the surgeon and intervention to prevent neurovascular damage. Moderate pain, expected drainage, and the presence of an abduction pillow are normal findings.

The principle of least restrictive intervention requires the nurse to first assess for and address any underlying physiological or psychological causes of agitation before resorting to restraints. In a client with dementia, agitation can be a sign of pain, hypoxia, infection, constipation, or other discomforts they cannot verbalize. A physician's order is required for restraints, but only after less restrictive measures have failed. Applying restraints without a thorough assessment is inappropriate.