NCLEX-PN

Practice Exam 1. Which of these would be the most appropriate way to document a client’s refusal of medication? A.​ “The client refused the heparin injection when I tried to administer it. She yelled at me saying, ‘I do not want that injection right now!’ and told me to leave the room. I explained the risks of not taking the medication. She seemed very annoyed that I tried to give it at that time. I will attempt again later in my shift.” B.​ “Ct stated she did not want the SQ heparin injected at this time. Risks of not taking this med were reviewed with the ct and ct verbalized understanding.” C.​ “Subcutaneous Heparin injection was attempted to be given to the client per the physician’s order. Client refused, stating, ‘I do not want that injection.’ Potential risks for refusing the medication were reviewed with the client and client verbalized understanding.” D.​ “Heparin refused during the shift. Risks reviewed.” Correct Response: C Explanation: The correct answer is (C) . This documentation method provides an objective and concise account of the client's refusal of medication. It states that a subcutaneous Heparin injection was attempted as per the physician's order, the client refused, and the potential risks for refusing the medication were reviewed, with the client verbalizing understanding. This documentation adheres to the principles of clear, accurate, and objective record-keeping in healthcare. (A), (B), and (D) are incorrect for various reasons. (A) introduces subjective language, potentially clouding the objective documentation required in healthcare records. (B) lacks essential details about the attempted administration and is less comprehensive in describing the verbalized understanding. (D) is too brief, offering minimal information about the refusal and lacking specificity in terms of who conducted the risk review and the client's response.(See Record & Communicate ) 2. The LPN is caring for a 9 month-old infant. Which of these behaviors exhibited by the child warrants further investigation?

A.​ She seems distressed with new adults. B.​ She only babbles “mama” and “dada.” C.​ She prefers crawling and is making no attempt to walk. D.​ She does not respond to her own name. Correct Response: D

Explanation: The correct answer is (D) , as the behavior that warrants further investigation in a 9-month-old infant is the failure to respond to her own name. By 9 months of age, infants typically exhibit the ability to recognize and respond to familiar voices, including their own name, serving as a crucial indicator of social and cognitive development. The absence of responsiveness to her name may raise concerns regarding potential issues related to hearing, language acquisition, or social engagement. In contrast, the other provided behaviors—being distressed with new adults (A) , babbling "mama" and "dada" (B) , and preferring crawling over walking (C) —are generally considered within the expected range of developmental variations for a child of this age. Being distressed with new adults is a common

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