NCLEX-PN Test #5 1 — Questions and Answers
Question 1: A licensed practical nurse (LPN) is working with a registered nurse (RN) and two unlicensed assistive personnel (UAP). Which task is appropriate to delegate to a UAP?
- Obtaining a fingerstick blood glucose on a stable diabetic client (Correct answer)
- Changing a sterile wound dressing on a postoperative client
- Administering a scheduled oral medication to a stable client
- Performing initial admission assessment for a newly admitted client
Correct answer: Obtaining a fingerstick blood glucose on a stable diabetic client
UAPs can perform routine, non-invasive tasks for stable clients after appropriate training, such as fingerstick blood glucose checks. Sterile dressing changes, medication administration, and initial assessments require nursing judgment and are within the LPN or RN scope of practice.
Question 2: An LPN working the night shift has four clients. Which client should the nurse assess first?
- A client with COPD requesting a breathing treatment
- A client with type 2 diabetes reporting diaphoresis and shakiness (Correct answer)
- A client who had a hip replacement yesterday requesting pain medication
- A client with hypertension whose blood pressure is 148/92 mmHg
Correct answer: A client with type 2 diabetes reporting diaphoresis and shakiness
Diaphoresis and shakiness in a diabetic client are classic signs of hypoglycemia, which can progress rapidly to seizures, loss of consciousness, and death if untreated. This is the most time-sensitive emergency and must be assessed first. The other clients have less immediately life-threatening presentations.
Question 3: During medication administration, a nurse realizes she accidentally gave a client the wrong dose of atenolol (gave 100 mg instead of 50 mg). The client's current pulse is 58 bpm. What should the nurse do first?
- Complete an incident report and notify the charge nurse
- Assess the client's vital signs and notify the provider immediately (Correct answer)
- Document the error in the chart and monitor the client closely
- Administer atropine as a precaution per standing orders
Correct answer: Assess the client's vital signs and notify the provider immediately
After a medication error, client safety is the top priority. The nurse must first fully assess the client and notify the provider immediately so interventions can be ordered if needed. An incident report is also required but comes after ensuring client safety. Atropine is not given prophylactically.
Question 4: A charge nurse is delegating morning care tasks. Which assignment should the charge nurse question?
- Asking a UAP to bathe a stable, ambulatory postpartum client
- Asking an LPN to administer scheduled oral medications to stable clients
- Asking a UAP to perform a urinary catheter insertion on a client (Correct answer)
- Asking an LPN to reinforce teaching provided by the RN about a low-sodium diet
Correct answer: Asking a UAP to perform a urinary catheter insertion on a client
Urinary catheter insertion is a sterile procedure that requires nursing skills and is within the LPN scope of practice — it should not be delegated to a UAP. UAPs can provide basic care (bathing, feeding) for stable clients. LPNs can administer medications and reinforce (not initiate) patient teaching.
Question 5: A nurse is caring for a client who refuses a blood transfusion for religious reasons despite a hemoglobin of 6.2 g/dL. The provider has ordered the transfusion. What is the nurse's most appropriate action?
- Administer the transfusion because it is medically necessary
- Ask the family to convince the client to accept the transfusion
- Respect the client's refusal, document it, and notify the provider (Correct answer)
- Consult hospital security before proceeding
Correct answer: Respect the client's refusal, document it, and notify the provider
A competent adult client has the legal and ethical right to refuse any treatment, including blood transfusions, for any reason including religious beliefs. The nurse must document the refusal, notify the provider, and ensure the client understands the risks. Administering treatment against the client's will is battery.
Question 6: A nurse is preparing to give a client a scheduled medication when the client states, 'I don't think that's the right pill — mine is usually white and round.' Which is the most appropriate nursing response?
- Reassure the client that medications often look different between manufacturers
- Hold the medication and verify the order before administration (Correct answer)
- Administer the medication because it was prepared by the pharmacy
- Ask another nurse to confirm it is the correct medication
Correct answer: Hold the medication and verify the order before administration
A client questioning their medication is an important safety cue. The nurse should hold the medication and verify the order with the pharmacy and the medication administration record before giving it. This is a key patient safety and medication error prevention practice.
NCLEX-PN Test #5 1
A licensed practical nurse (LPN) is working with a registered nurse (RN) and two unlicensed assistive personnel (UAP).
Which task is appropriate to delegate to a UAP?