NCLEX PN 2

NCLEX-PN 2020 EXAM QUESTIONS, ANSWERS AND RATIONALES 1. Which educational nursing program takes 2 to 5 years to complete? a. Nursing assistant (NA) program b. Practical nursing (LPN, LVN) program c. Professional nursing program d. Advanced practice nursing (APN) program The professional nursing program (RN) requires 2 to 5 years of education, depending on the type of degree sought. An NA program takes 6 to 8 weeks. An LPN/LVN program takes 12 to 18 months. An APN program takes more than 4 years. 2. Who established the Henry Street Settlement Service in New York City? a. Lillian Wald b. Dorothea Dix c. Florence Nightingale d. Richard Bradley Lillian Wald took nursing into the community and established the Henry Street Settlement Service in 1893. Dorothea Dix organized volunteers to provide nursing care to soldiers during the Civil War. Florence Nightingale trained women to care for the sick during the Crimean War. Richard Bradley opened a practical nursing school in 1907. 3. Which is included in the six levels of care within the health care system? a. Skilled b. Post-acute c. Restorative d. Hospice The six levels of care within the health care system include: preventative, primary, secondary, tertiary, restorative, and continuing care. 4. In the 20th century, nurses moved into: a. Hospitals b. Long-term care facilities c. The community d. State mental health facilities In the 20th century nurses began working in the community with the poor, providing midwifery services and education regarding prenatal, obstetrics, and child care. 5. What was the intent of diagnosis-related groups (DRGs)? a. Offer more health care services b. Extend hospital stays c. Improve health care d. Contain health care costs DRGs were created by the Medicare program in 1983 as an attempt to contain health care costs. DRGs do not offer more services. The intent of DRGs was not to extend hospitalizations. The purpose of DRGs was specifically to contain costs. 6. The goals of nursing include: Select all that apply. a. to promote wellness. b. to prevent illness. c. to facilitate coping. d. to restore health. The four common goals of nursing care are to promote wellness, prevent illness, facilitate coping, and restore health. 7. Which educational nursing program attracts the majority of registered nurse (RN) students? a. Associate degree program b. Diploma program c. Baccalaureate program d. Graduate program The associate degree program attracts the majority of RN students. The number of diploma schools has decreased. Baccalaureate programs take longer to complete and have fewer students. Graduate programs take longer to complete and have fewer students. 8. What is the third step of the nursing process? a. Planning b. Evaluation c. Implementation d. Nursing diagnosis Planning is the third step of the nursing process. Evaluation is the last step of the nursing process. Implementation occurs after planning. Nursing diagnosis is the second step of the nursing process. 9. One of the highest priorities of nursing care is: a. adequate nutrition. b. maintaining skin integrity. c. pain control. d. airway management. In prioritizing care, physiologic needs for basic survival take precedence. Airway management always comes first. Without an adequate airway, a patient will die. Nutrition, maintaining skin integrity, and pain control are lower priorities of care than airway management. 10. A nurse is educating a group of elderly patients in an assisted-living facility about urinary incontinence. Information offered during the encounter may include: a. Avoidance of Kegel exercises b. Wear adult diapers day and night to prevent leakage c. Condom catheters may be used by males d. Indwelling Foley catheters are recommended for management of all types of incontinence Condom catheters are appropriate for males if used correctly. Kegel exercises are recommended and may greatly reduce or stop incontinence. Adult diapers are not to be worn 24 hours a day as a result of an increased risk of skin breakdown. Indwelling Foley catheters are not appropriate for all types of incontinence, and the risks associated with trauma and infection may outweigh the benefits. 11. A nurse should notify the physician if: a. 24-hour urine output is 700 mL b. 24-hour urine output is 800 mL c. 24-hour urine output is 720 mL d. 24-hour urine output is 1000 mL Average hourly urine output is 30 mL, therefore 700 mL in a 24 hour period is abnormal because it averages to less than 30 mL/hour. The remaining options reflect urine output within normal range for a 24-hour period. 12. A female patient has had a knee replacement and is experiencing difficulty voiding. What should the nurse recommend? a. Pour warm water over the perineum while patient attempts to void b. Catheterize the patient to avoid problems c. Use Crede’s maneuver per nursing order d. Use a sitz bath per nursing order Warm water may help patients to initiate the voiding reflex. Catheterization is used after other techniques have been unsuccessful. A physician order is needed for use of Crede's maneuver and/or a sitz bath. 13. Which bacterium is most often responsible for cystitis? a. Proteus b. Escherichia coli c. Pseudomonas d. Enterococcus Escherichia coli is often the bacterium responsible for cystitis, especially in females. Proteus, Pseudomonas, and Enterococcus may cause cystitis but are not considered the most common causes. 14. Who was the first visiting nurse? a. Florence Nightingale b. Phoebe c. Dorothea Dix d. Clara Barton Phoebe was a practical nurse in Rome and became the first visiting nurse. Florence Nightingale trained women to care for the sick during the Crimean War. Dorothea Dix organized women volunteers to provide nursing care for soldiers during the Civil War. Clara Barton took volunteers into the field hospitals to care for soldiers of both armies during the Civil War. 15. Which was the first care delivery system for practical nurses? a. Team nursing b. Functional nursing care c. Total patient care d. Primary nursing Functional nursing care was the first care delivery system for the practical nurse. Team nursing evolved in the 1950s. Total patient care came after team nursing. Primary nursing appeared in the late 1960s and 1970s. 16. Which is considered a low-priority patient in the emergency room? a. Patient with a laceration to the leg b. Patient with an ankle fracture c. Patient with a sore throat d. Patient with a gunshot wound to the chest A sore throat is of low priority compared with the other aforementioned medical problems. A patient with a laceration to the leg or an ankle fracture is of higher priority than the patient with a sore throat. Life-threatening problems are of a high priority; therefore a patient with a gunshot wound to the chest is of highest priority. 17. Which are components of the nursing process? Select all that apply. a. Assessment b. Nursing diagnosis c. Management d. Evaluation Assessment, nursing diagnosis, and evaluation are three of the five components of the nursing process (accompanied by planning and implementation). Management is not one of the five components of the nursing process. 18. The steps of the problem-solving process include: a. nursing diagnosis. b. identification of problem. c. critical thinking. d. management of problem. The first step is to define the problem clearly. Nursing diagnosis and management are not steps in the problem-solving process. Critical thinking is required, but is not an actual step in the process. 19. Critical thinking involves: a. randomly organizing tasks. b. utilization of past solutions. c. purposeful mental activity. d. traditional problem-solving methods. Critical thinking is a directed and purposeful mental activity. Critical thinking involves priority setting, production of new solutions, and creative problem solving. 20. Prioritizing patient problems is usually based on: a. Maslow's hierarchy of needs. b. the nurse-to-nurse report. c. managerial influence. d. nonspecific data collection. Maslow's hierarchy of needs is used to set priorities in nursing situations. Priority setting is not based on the nurse-to-nurse report or managerial influence. Gathering of information specific to each patient is necessary for priority setting. 21. What do concept maps do? a. Solve nursing dilemmas b. Require the problem-solving process c. Promote critical thinking d. Are used only by student nurses Concept mapping helps to gather data in a logical manner and then group the data in a meaningful way in an effort to promote critical thinking skills. Concept mapping does not solve nursing dilemmas, but shows relationships between concepts. Concept mapping does not require the problem-solving process, but it may be helpful. Concept mapping is not used only by student nurses. 22. Which statement is true regarding a plan of care for a patient? a. Plans of care should not change so continuity is maintained. b. LPNs/LVNs are responsible for initiating nursing care plans. c. Patient input is not beneficial. d. Plans of care should be a collaborative process. Plans of care should be a collaborative process among nurses, patients, and other health team members. Plans of care should be altered as clients' conditions change. RNs are officially responsible for initiating nursing care plans. Patient input in the planning stage results in more success with the care plan. 23. What is the initial nursing intervention in preventing polypharmacy? a. Obtain a thorough medication history. b. Discontinue all herbal preparations. c. Refer the patient to a geriatric practitioner. d. Consult a pharmacist to review all medications. A thorough medication history is the initial step in preventing polypharmacy. A comprehensive assessment can help maintain a therapeutic medication regimen, identify educational needs, eliminate unnecessary medications, and reduce the risk of adverse drug reactions. Discontinuation of vitamins, herbs, and medications is not a nursing intervention. A referral should be ordered by a physician. Consultation with a pharmacist would be beneficial, but a thorough medication history is the first intervention. 24. Which statement is true regarding falls in the elderly? a. Most falls occur in the garage. b. Hip fractures resulting from falls are a leading cause of placement in long-term care facilities. c. Fall risk decreases with addition of medications. d. Sedatives reduce the risk of falls. Hip fractures are a leading cause of hospitalization and placement in long-term care facilities. Most falls occur in the bedroom or bathroom. With each additional medication consumed, the risk of falls is increased. Sedatives can decrease alertness and reaction times which can lead to falls. 25. Appropriate nursing care for a patient with urinary incontinence is to: a. insert an indwelling Foley catheter. b. order oxybutynin chloride (Ditropan). c. encourage fluids to decrease the urine concentration so it is less irritating. d. recommend herbal approaches to reduce incontinence. Encouraging fluids can decrease the urine concentration so it is less irritating, less predisposing to urinary tract infections, and less odoriferous. Indwelling catheters are not recommended. Nurses may not order/prescribe medications. Nurses should not recommend herbal preparations without first consulting with the physician. 26. Which age-related changes predispose the elderly patient to drug toxicity and extended duration of action of drugs? Select all that apply. a. Decreased body water b. Increased ratio of muscle to fat c. Low serum albumin d. Reduced blood flow to liver Decreased body water, low serum albumin, and reduced blood flow to the liver are age-related changes that predispose the elderly patient to drug toxicity. The elderly have an increased ratio of fat to muscle. 27. A patient with dysphagia is: a. fed only for pleasure b. at low risk for nutritional deficits c. at higher risk for pneumonia d. able to drink thin liquids Patients with dysphagia (difficulty swallowing) should be positioned upright or in a high Fowler's position and fed very small amounts to avoid aspiration and aspiration pneumonia. A patient with dysphagia is at higher risk for developing a nutritional deficit. Liquids may need to be thickened. 28. Which is of highest priority for a nurse on a general medical unit? a. Patient with chest pain b. Patient with diarrhea c. Patient with productive cough d. Patient with a low-grade fever Life-threatening problems are of a high priority. Chest pain can be life-threatening, requires immediate attention, and is of the highest priority for the nurse. A patient with diarrhea, a productive cough, and/or a low-grade fever is not of the highest priority. 29. A registered nurse (RN) delegates to a licensed practical nurse the task of monitoring intake and output for all patients who have been treated for heart failure on a cardiac medical unit. The unit manager is reviewing the effectiveness of heart failure management on the unit. Delegation is included in which component of the nursing process? a. Implementation b. Nursing diagnosis c. Develop solutions d. Planning Delegation may be used in the implementation process. Delegation is not a nursing diagnosis. Delegation is not a part of the development of solutions, which is a component of the scientific method process. Delegation is more applicable in the implementation step than the planning step. 30. A licensed practical nurse (LPN) may supervise which of the following? Select all that apply. a. Nursing assistants (NAs) b. Nurse technicians c. LPNs d. Registered nurses (RNs) An LPN may supervise NAs, nurse technicians, and other LPNs. An LPN may not supervise RNs. 31. Nurses work in patient situations that give them permission to do what is usually not permitted in other circumstances. This is consistent with which legal term? a. Ethics b. Privilege c. Advocacy d. Competency Nurses are given privilege to a client's body and emotions. Laws define the boundaries of that privilege. Ethics or ethical principles are rules of conduct that have been agreed to by a particular group and used to determine right and wrong. Advocacy is defined as the act of supporting a cause or a purpose. To be competent is to be mentally and emotionally able to understand and act (make choices). 32. Psychiatric patients can be held against their will in which situation? a. Unable to provide for basic needs b. Major depression c. Homelessness d. Substance abuse Patients with psychiatric disorders in most states cannot be held against their will for more than 3 days, unless they are a distinct danger to self or others, or are gravely disabled (unable to provide for basic needs). Major depression, homelessness, and substance abuse alone are not reasons to hold patients against their will. 33. Informed consent may be given by a: a. stepparent of a non-adopted child. b. 80-year-old with dementia. c. 72-year-old who has just taken morphine sulfate. d. competent 19-year-old who has just taken Tylenol. A competent person over the age of 18 may give informed consent. Tylenol is not a mindaltering drug. Stepparents usually cannot give consent unless the child is legally adopted. Cognitively impaired individuals may not give informed consent. Informed consent may not be given by an individual under the influence of a narcotic. 34. Which is a true statement? a. Employers may ask about health status on an employment application. b. Sexual harassment is illegal when it interferes with job performance. c. Student nurses are not held to the same standards as a licensed nurse. d. In a case of child abuse, the account of injury given by the caregiver is consistent with physical signs and symptoms. Sexual harassment is illegal when used as a condition of employment or promotion or when it interferes with job performance. Employers may not ask about health status. Student nurses are held to the same standards as a licensed nurse. The account of injury is often inconsistent with signs and symptoms. 35. Which statement is true regarding advance directives? a. Advance directives expire. b. Emergency medical technicians may honor advance directives. c. A living will is a type of advance directive. d. Do-not-resuscitate (DNR) orders are written by nurses. A living will and medical power of attorney are two types of advance directives. Advance directives do not expire. EMTs cannot honor advance directives. DNRs are written by physicians. 36. Which age-related change in the urinary system should a nurse expect? a. Increased bladder tone b. Episodes of incontinence c. Increased red blood cells (RBCs) in the urine d. Reduced rate of renal filtration Reduced rate of renal filtration occurs with aging and may lead to a decrease in renal function. The bladder tone decreases with aging. Incontinence is not a normal part of aging. Increased RBCs is not an age-related change. 37. A nurse is collecting a voided specimen for urinalysis. The nurse should: a. Tell the patient it is necessary to fill the container b. Send the urine to the laboratory within 20 minutes c. Tell the patient to use sterile technique d. Tell the patient that only about 1.5 inches of urine is needed When collecting a voided specimen for urinalysis, it is not necessary to fill the container with urine; only about 1.5 inches of urine is needed. Send the urine within 5 to 10 minutes. Sterile technique is not needed. 38. What are the functions of the urinary structures for elimination? Select all that apply. a. The urethra carries urine from the kidneys to the bladder b. Urine output is related to the amount of fluid intake c. Waste products are diluted with water and excreted as urine d. A bladder can hold 2500 mL of urine Urine output is related to fluid intake and can vary considerably. Waste products are excreted as urine. Ureters carry urine from the kidneys to the bladder. A bladder can hold 1000 to 1800 mL of urine. 39. One of the most common charges brought against nurses is: a. Discrimination b. Defamation c. Incompetence d. Libel The most common charges brought against nurses include substance abuse, incompetence, and negligence. A nurse can be charged with incompetence if something was done that could or did harm a patient, such as a medication error. Discrimination, defamation, and libel are not common charges against nurses. 40. Which is true regarding assisted suicide? a. A constitutional right exists for physician-assisted suicide. b. Participation in assisted suicide is a violation of the American Nurses Association (ANA) Code for Nurses. c. Assisted suicide is a crime in all states. d. Assisted suicide is the same as euthanasia. Participation in assisted suicide violates the ethical principle of "do no harm." No constitutional right exists for assisted suicide. (Assisted suicide is not a crime in Oregon.) Assisted suicide is not the same as euthanasia, which is described as mercy killing. 41. An unexpected patient care occurrence that results in death or serious injury to the patient is: a. negligence. b. malpractice. c. a tort. d. a sentinel event. A sentinel event is an unexpected patient care event that results in death or serious injury (or risk of injury) to the patient. Negligence is failing to do something a reasonable prudent person would or would not do. Malpractice is negligence by a professional person. A tort is a violation of a civil law. 42. Age-related eye changes may include: a. increased visual accommodation b. macular degeneration c. non-preventable blindness as a result of glaucoma d. decreased ability of pupil to respond to light changes Because of macular degeneration, an elderly person gradually loses acute, central, and color vision. Visual accommodation decreases. Glaucoma is a frequent cause of preventable blindness. With age, the iris has decreased ability to respond to light changes. 43. Nurses' knowledge of sexuality in the older adult population should include: a. Chronic illness may affect the ability to participate in sexual activity. b. Sexual response time is unchanged. c. Ability to achieve orgasm declines. d. Dryness of the vaginal walls is associated with pelvic inflammatory disease. Chronic illness or disability may affect the ability to participate in sexual activity. Sexual response time slows with age. Ability to achieve orgasm continues. Vaginitis may occur as a result of thinning and dryness of the vaginal walls. 44. A nursing intervention for a patient with constipation is to: a. avoid the urge to defecate b. limit fluid intake c. give prune juice with a noncarbonated drink d. encourage bran cereal or whole-grain breads Patient teaching for the client with constipation should include encouraging bran cereal and/or whole-grain breads for increased fiber intake. Encourage the patient to heed the urge to defecate quickly. Encourage fluid intake of at least 2500 mL/day. Prune juice with carbonated drink may be recommended. 45. What should the nurse include in the teaching plan for self-medication practices of older adults? a. Eliminate unnecessary medications b. Substitute herbal preparations for certain prescribed medications c. Develop a drug reminder system and schedule d. Pharmacy shop for the cheapest medications. A drug reminder system and schedule can help decrease confusion and increase compliance with medications. Recommend physician review of all medicines. The physician should discontinue unnecessary medications. Nurses should not substitute for any medications unless ordered by the physician. Recommend that most or all medications be obtained from one pharmacy to avoid medication inconsistencies and problems. 46. Which is a long-term goal for a patient? a. Pain management b. Stroke rehabilitation c. Adequate fluid intake d. Treatment of a urinary tract infection (UTI) Long-term goals often relate to rehabilitation. Stroke rehabilitation will require more time than short-term goals, which are achievable within 7 to 10 days. Pain management, adequate fluid intake, and treatment of UTI are considered short-term goals. 47. To conduct a physical examination of a patient, which examination technique is used? a. Percussion of an area b. Weighing of a patient c. History taking d. Communication Inspection, auscultation, palpation, and percussion are examination techniques. Weighing a patient, history taking, and communication are not considered examination techniques. 48. Which stages are included in an interview? Select all that apply. a. Opening b. Body c. Discussion d. Closing The opening, the body, and the closing are stages in an interview. Discussion is not a stage in an interview. 49. For Medicare, a reassessment of a patient in a long-term care facility must be done every: a. 30 days. b. 60 days. c. 90 days. d. 120 days. For Medicare patients, a reassessment by a registered nurse is necessary every 90 days. 50. Which is an example of objective data? a. Pain b. Temperature c. Headache d. Lightheadedness Information obtained through the senses and hands-on physical examinations are objective data. Vital signs, including temperatures, are objective data. Pain, headache, and lightheadedness are considered subjective data.