Kaplan NCLEX-PN Question
Trainer Series | 250 Practice
Questions and Verified
Answers
Ethical Standards - answer-a. Respect for human dignity—give respectful service
regardless of client's personal characteristics
b. Confidentiality—does not discuss condition with anyone not involved with care
c. Competence—has knowledge and skills to provide care
d. Advocacy—protects client from incompetent or unethical practice
e. Research—participates in process of scientific inquiry
f. Promotion of public health—committed to local and global goals for health of
community
Clients Bill of Rights - answer-"A. Privacy"
"B. Respectful care"
"C. Current information"
"D. Informed consent"
"E. Confidentiality"
"F. Refusal of treatment"
"G. Reasonable response to a request for services"
"H. Right to know hospital/ clinic regulations"
Nursing Considerations for Restraints - answer-1. Observe and document need for
restraints (risk for falls, risk of injury to others, potential for removal of IV lines or other
equipment)
2. Consider and document use of alternative measures
3. Health care provider's order is required specifying duration and circumstances under
which restraints should be used
4. Cannot order restraints to be used PRN
5. Monitor client closely, periodically observe for continued need for restraints,
document
6. Remove for skin care and range of motion exercises
7. Use alternative measures prior to use of restraints (reorientation, family involvement,
frequent assistance with toileting)
Negligence - answer-unintentional failure of individual to perform an act that a
reasonable person would or would not perform in similar circumstances; can be act of
omission or commission
,Assault - answer-intentional threat to cause harm or offensive unwanted contact; battery
— intentional touching without consent
False Imprisonment - answer-1. Client is denied discharge from a health care facility
2. Client is denied discharge after signing an against medical advice (AMA) document
3. Client is placed in restraints without appropriate medical need
Tarasoff Act - answer-duty to warn of threatened suicide or harm to others
RN Scope of Practice (can be delegated to RN) - answer-1) Performs assessments
2) Admits new clients
3) Discharges clients
4) Cares for complex clients
5) Retains care of clients with diagnoses unique to the unit (particularly in situations of
"pulled" or reassigned nurses)
6) Performs client and family teaching about new diagnoses, diagnostic tests,
medications, skills for self-care, and discharge/home care
LPN Scope of Practice (can be delegated to LPN) - answer-1) Assist with
implementation of defined plan of care
2) Perform procedures according to protocol
3) Differentiate normal from abnormal, report data to RN
4) Care for physiologically stable clients with predictable conditions
5) Has knowledge of asepsis and dressing changes
6) Ability to administer medications varies with educational background and state nurse
practice act
UAP/CNA Scope of Practice (can be delegated to UAP) - answer-1) Assist with direct
client care activities (bathing, transferring, ambulating, feeding, toileting, obtaining vital
signs, height, weight, intake and output, housekeeping, transporting, stocking supplies)
2) Includes nurses' aides, assistants, technicians, orderlies, nurse extenders
3) Scope of nursing practice is limited
Common situations that require an incident report - answer-1. Medication errors—
omitted medication, wrong medication, wrong dosage, wrong route
2. Complications from diagnostic or treatment procedures (e.g., blood sample stick,
biopsy, x-ray, LP, invasive procedure, bronchoscopy, thoracentesis)
3. Incorrect sponge count in surgery
4. Failure to report change in client's condition
5. Falls
6. Client is burned
7. Break in aseptic technique
8. Medical—legal incident
............a. Client or family refuses treatment as ordered and refuses to sign consent
,............b. Client or family voices dissatisfaction with care and situation cannot be or has
not been resolved
ANA Code of Ethics—decision-making framework for solving ethical problems - answer-
1. Nurse provides care with respect for human dignity and uniqueness of individual
without consideration of social or economic status, personal attributes, or nature of
health problems
2. Nurse safeguards the client's right to privacy
3. Nurse acts to safeguard client and public when health care and safety are at risk from
incompetent, unethical, or illegal practice of an individual
4. Nurse assumes responsibility and accountability for own individual actions and
judgments
5. Nurse maintains competence in nursing
6. Nurse uses informed judgment, competence, and qualifications in accepting
responsibilities and delegating nursing activities to others
7. Nurse participates in activities contributing to the development of the profession's
body of knowledge
8. Nurse participates in profession's efforts to implement and improve standards of care
9. Nurse participates in profession's efforts to establish and maintain conditions of
employment conducive to high-quality nursing care
10. Nurse participates in profession's efforts to protect the public from misinformation
and misrepresentation and to maintain the integrity of nursing
11. Nurse collaborates with members of the health professions and others to promote
community and national efforts to meet the health care needs of the public
Ethical Principles of Nursing - answer-1. Autonomy—support of client's independence to
make decisions and take action for themselves
2. Beneficence—duty to help others by doing what is best for them; client advocacy for
refusal of care, autonomy overrides beneficence
3. Nonmaleficence—"do no harm"; act with empathy toward client and staff without
resentment or malice; violated by acts performed in bad faith or with ill will, or when
making false accusations about client or employee
4. Justice—use available resources fairly and reasonably
5. Veracity—communicate truthfully and accurately
6. Confidentiality—safeguard the client's privacy
7. Fidelity—following through on what the nurse says will be done; carefully attending to
the details of the client's care
Data Collection for Infections - answer-1. Local (focal point)—heat, redness,
pain/tenderness, swelling, possible drainage (bloody, serous, purulent), abscess
(localized collection of pus), cellulitis (involving cellular and connective tissue)
2. Systemic (generalized)—fever, malaise, weakness
3. White blood cell count (WBC)—normally 4,500-11,000 × 103/mm3; increase indicates
the presence of disease or injury; differential of 30-40% lymphocytes; increased number
immature neutrophils ("shift to left")
, 4. Erythrocyte sedimentation rate (ESR)—elevations greater than 15-20 mm/hr indicate
the presence of inflammation
5. Cultures and antibiotic sensitivity of suspected infectious site
...........a. Should be obtained before onset of antibiotic therapy
...........b. Specimens must be carefully collected and identified
...........c. Preliminary results in 24 hours; final results in 72 hours
6. Highly sensitive C-reactive protein (hsCRP)—marker of inflammation
Diagnose Infection - answer-1. Inflammation—immediate, short-term, nonspecific
response to the adverse effects of injury, i.e., physical irritants (trauma/foreign body) or
chemical irritants (strong acids/ alkalies) or invasion by microorganisms
2. Communicable diseases—caused by pathogenic microorganisms and transmitted by
direct contact, droplet spread, contaminated articles, or through carriers (see Table 1)
3. Hospital-Acquired Infections (HAI)—nearly 2 million (5%) hospital clients acquire an
infection in the hospital; most often caused by Staphylococcus aureus
Plan/Implementation of Infection - answer-1. Treatment of infection or infectious disease
with appropriate antibiotic medication
2. Standard precautions (barrier)—used with all clients
..........a. Primary strategy for infection control in all settings
..........b. Most important way to reduce transmission of pathogens
Clinical Picture of Chickenpox (Varicella) (13-17 days) - answer-Prodromal: slight fever,
malaise, anorexia
Rash is pruritic, begins as macule, then papule, and then vesicle with successive crops
of all three stages present at any one time; lymphadenopathy; elevated temperature
Transmission of Chickenpox (Varicella) - answer-spread by direct contact, airborne,
contaminated object
Nursing Considerations of Chickenpox (Varicella) - answer-Isolation until all vesicles are
crusted; communicable from 1 day before rash
Avoid use of aspirin due to association with Reye syndrome; use acetaminophen
Topical application of calamine lotion or baking soda baths
Airborne and contact precautions in hospital
Diphtheria (2-5 days): Clinical Picture - answer-Prodromal: resembles common cold
Low-grade fever, hoarseness, malaise, pharyngeal lymphadenitis; characteristic
white/gray pharyngeal membrane
Diphtheria (2-5 days): Transmission - answer-direct contact with a carrier, infected client
contaminated articles
Diphtheria (2-5 days): Nursing Considerations - answer-Contact and droplet precautions
until two successive negative nose and throat cultures are obtained
Trainer Series | 250 Practice
Questions and Verified
Answers
Ethical Standards - answer-a. Respect for human dignity—give respectful service
regardless of client's personal characteristics
b. Confidentiality—does not discuss condition with anyone not involved with care
c. Competence—has knowledge and skills to provide care
d. Advocacy—protects client from incompetent or unethical practice
e. Research—participates in process of scientific inquiry
f. Promotion of public health—committed to local and global goals for health of
community
Clients Bill of Rights - answer-"A. Privacy"
"B. Respectful care"
"C. Current information"
"D. Informed consent"
"E. Confidentiality"
"F. Refusal of treatment"
"G. Reasonable response to a request for services"
"H. Right to know hospital/ clinic regulations"
Nursing Considerations for Restraints - answer-1. Observe and document need for
restraints (risk for falls, risk of injury to others, potential for removal of IV lines or other
equipment)
2. Consider and document use of alternative measures
3. Health care provider's order is required specifying duration and circumstances under
which restraints should be used
4. Cannot order restraints to be used PRN
5. Monitor client closely, periodically observe for continued need for restraints,
document
6. Remove for skin care and range of motion exercises
7. Use alternative measures prior to use of restraints (reorientation, family involvement,
frequent assistance with toileting)
Negligence - answer-unintentional failure of individual to perform an act that a
reasonable person would or would not perform in similar circumstances; can be act of
omission or commission
,Assault - answer-intentional threat to cause harm or offensive unwanted contact; battery
— intentional touching without consent
False Imprisonment - answer-1. Client is denied discharge from a health care facility
2. Client is denied discharge after signing an against medical advice (AMA) document
3. Client is placed in restraints without appropriate medical need
Tarasoff Act - answer-duty to warn of threatened suicide or harm to others
RN Scope of Practice (can be delegated to RN) - answer-1) Performs assessments
2) Admits new clients
3) Discharges clients
4) Cares for complex clients
5) Retains care of clients with diagnoses unique to the unit (particularly in situations of
"pulled" or reassigned nurses)
6) Performs client and family teaching about new diagnoses, diagnostic tests,
medications, skills for self-care, and discharge/home care
LPN Scope of Practice (can be delegated to LPN) - answer-1) Assist with
implementation of defined plan of care
2) Perform procedures according to protocol
3) Differentiate normal from abnormal, report data to RN
4) Care for physiologically stable clients with predictable conditions
5) Has knowledge of asepsis and dressing changes
6) Ability to administer medications varies with educational background and state nurse
practice act
UAP/CNA Scope of Practice (can be delegated to UAP) - answer-1) Assist with direct
client care activities (bathing, transferring, ambulating, feeding, toileting, obtaining vital
signs, height, weight, intake and output, housekeeping, transporting, stocking supplies)
2) Includes nurses' aides, assistants, technicians, orderlies, nurse extenders
3) Scope of nursing practice is limited
Common situations that require an incident report - answer-1. Medication errors—
omitted medication, wrong medication, wrong dosage, wrong route
2. Complications from diagnostic or treatment procedures (e.g., blood sample stick,
biopsy, x-ray, LP, invasive procedure, bronchoscopy, thoracentesis)
3. Incorrect sponge count in surgery
4. Failure to report change in client's condition
5. Falls
6. Client is burned
7. Break in aseptic technique
8. Medical—legal incident
............a. Client or family refuses treatment as ordered and refuses to sign consent
,............b. Client or family voices dissatisfaction with care and situation cannot be or has
not been resolved
ANA Code of Ethics—decision-making framework for solving ethical problems - answer-
1. Nurse provides care with respect for human dignity and uniqueness of individual
without consideration of social or economic status, personal attributes, or nature of
health problems
2. Nurse safeguards the client's right to privacy
3. Nurse acts to safeguard client and public when health care and safety are at risk from
incompetent, unethical, or illegal practice of an individual
4. Nurse assumes responsibility and accountability for own individual actions and
judgments
5. Nurse maintains competence in nursing
6. Nurse uses informed judgment, competence, and qualifications in accepting
responsibilities and delegating nursing activities to others
7. Nurse participates in activities contributing to the development of the profession's
body of knowledge
8. Nurse participates in profession's efforts to implement and improve standards of care
9. Nurse participates in profession's efforts to establish and maintain conditions of
employment conducive to high-quality nursing care
10. Nurse participates in profession's efforts to protect the public from misinformation
and misrepresentation and to maintain the integrity of nursing
11. Nurse collaborates with members of the health professions and others to promote
community and national efforts to meet the health care needs of the public
Ethical Principles of Nursing - answer-1. Autonomy—support of client's independence to
make decisions and take action for themselves
2. Beneficence—duty to help others by doing what is best for them; client advocacy for
refusal of care, autonomy overrides beneficence
3. Nonmaleficence—"do no harm"; act with empathy toward client and staff without
resentment or malice; violated by acts performed in bad faith or with ill will, or when
making false accusations about client or employee
4. Justice—use available resources fairly and reasonably
5. Veracity—communicate truthfully and accurately
6. Confidentiality—safeguard the client's privacy
7. Fidelity—following through on what the nurse says will be done; carefully attending to
the details of the client's care
Data Collection for Infections - answer-1. Local (focal point)—heat, redness,
pain/tenderness, swelling, possible drainage (bloody, serous, purulent), abscess
(localized collection of pus), cellulitis (involving cellular and connective tissue)
2. Systemic (generalized)—fever, malaise, weakness
3. White blood cell count (WBC)—normally 4,500-11,000 × 103/mm3; increase indicates
the presence of disease or injury; differential of 30-40% lymphocytes; increased number
immature neutrophils ("shift to left")
, 4. Erythrocyte sedimentation rate (ESR)—elevations greater than 15-20 mm/hr indicate
the presence of inflammation
5. Cultures and antibiotic sensitivity of suspected infectious site
...........a. Should be obtained before onset of antibiotic therapy
...........b. Specimens must be carefully collected and identified
...........c. Preliminary results in 24 hours; final results in 72 hours
6. Highly sensitive C-reactive protein (hsCRP)—marker of inflammation
Diagnose Infection - answer-1. Inflammation—immediate, short-term, nonspecific
response to the adverse effects of injury, i.e., physical irritants (trauma/foreign body) or
chemical irritants (strong acids/ alkalies) or invasion by microorganisms
2. Communicable diseases—caused by pathogenic microorganisms and transmitted by
direct contact, droplet spread, contaminated articles, or through carriers (see Table 1)
3. Hospital-Acquired Infections (HAI)—nearly 2 million (5%) hospital clients acquire an
infection in the hospital; most often caused by Staphylococcus aureus
Plan/Implementation of Infection - answer-1. Treatment of infection or infectious disease
with appropriate antibiotic medication
2. Standard precautions (barrier)—used with all clients
..........a. Primary strategy for infection control in all settings
..........b. Most important way to reduce transmission of pathogens
Clinical Picture of Chickenpox (Varicella) (13-17 days) - answer-Prodromal: slight fever,
malaise, anorexia
Rash is pruritic, begins as macule, then papule, and then vesicle with successive crops
of all three stages present at any one time; lymphadenopathy; elevated temperature
Transmission of Chickenpox (Varicella) - answer-spread by direct contact, airborne,
contaminated object
Nursing Considerations of Chickenpox (Varicella) - answer-Isolation until all vesicles are
crusted; communicable from 1 day before rash
Avoid use of aspirin due to association with Reye syndrome; use acetaminophen
Topical application of calamine lotion or baking soda baths
Airborne and contact precautions in hospital
Diphtheria (2-5 days): Clinical Picture - answer-Prodromal: resembles common cold
Low-grade fever, hoarseness, malaise, pharyngeal lymphadenitis; characteristic
white/gray pharyngeal membrane
Diphtheria (2-5 days): Transmission - answer-direct contact with a carrier, infected client
contaminated articles
Diphtheria (2-5 days): Nursing Considerations - answer-Contact and droplet precautions
until two successive negative nose and throat cultures are obtained
