NCLEX-PN
Nclex Exam Cram Practice Questions
1. A client who is immobilized secondary to traction is complaining of constipation. Which of the following medications should the nurse expect to be ordered?
- A. Advil
- B. Anasaid
- C. Clinocil
- D. Colace
Correct answer: D
Rationale: Colace is a stool softener that acts by pulling more water into the bowel lumen, making the stool soft and easier to evacuate. In the given scenario of constipation in an immobilized client, a stool softener like Colace is the appropriate choice to help facilitate bowel movements. Advil and Anasaid are nonsteroidal anti-inflammatory drugs (NSAIDs) used for pain relief, not for constipation. Clinocil is not a recognized medication for constipation relief.
2. The nurse is teaching a client about communicable diseases and explains that a portal of entry is:
- A. a vector.
- B. a source, like contaminated water.
- C. food.
- D. the respiratory system.
Correct answer: D
Rationale: The correct answer is 'the respiratory system.' A portal of entry is the path through which a microorganism enters the body. In the case of communicable diseases, the respiratory system can serve as a portal of entry for pathogens such as viruses or bacteria. Choices A, B, and C are incorrect. A 'vector' is an organism that transmits disease, not the entry point for pathogens. Contaminated water or food can act as sources or reservoirs of disease-causing microorganisms, not portals of entry.
3. A nurse is performing suctioning through an adult client's tracheostomy tube. The nurse notes that the client's oxygen saturation is 89% and terminates the procedure. Which action would the nurse take next?
- A. Rechecking the pulse oximetry reading
- B. Calling the respiratory therapist
- C. Calling the healthcare provider
- D. Oxygenating the client with 100% oxygen
Correct answer: D
Rationale: The nurse should monitor the client's heart rate and pulse oximetry during suctioning to assess the client's tolerance of the procedure. Oxygen desaturation to below 90% indicates hypoxemia. If hypoxia occurs during suctioning, the nurse must terminate the procedure and oxygenate the client with 100% oxygen to address the hypoxemia promptly and ensure the client's safety. Rechecking the pulse oximetry reading is important, but the priority is to address the hypoxemia by providing oxygen. Contacting the healthcare provider or respiratory therapist is not necessary at this time as the nurse can manage the hypoxemia with oxygenation. Oxygenating the client with 100% oxygen is the immediate action required in this situation.
4. The nurse is preparing to administer IV Vancomycin to a client. Which of the following nursing actions should be taken first?
- A. Performing a physical assessment prior to administration
- B. Obtaining the most recent lab values regarding renal function
- C. Reviewing peaks and troughs for the past few days
- D. Ensuring the client is not allergic to the medication
Correct answer: D
Rationale: Before administering any medication, including IV Vancomycin, it is crucial to ensure that the client is not allergic to the medication. This is the most critical action to prevent any potential allergic reactions. While performing a physical assessment is important, it may not be as time-sensitive as checking for allergies. Obtaining lab values related to renal function is also significant with Vancomycin due to its potential nephrotoxicity, but ensuring the client's safety by checking for allergies takes precedence. Reviewing peaks and troughs is important for monitoring drug levels, but it is a secondary step compared to checking for allergies prior to administration.
5. Ethics committees typically do not handle which of the following issues?
- A. Nonpayment of bills.
- B. Euthanasia.
- C. Starting or stopping treatment.
- D. Use of feeding tubes.
Correct answer: A
Rationale: Ethics committees primarily focus on addressing ethical dilemmas in healthcare. Issues like euthanasia, decisions regarding starting or stopping treatment, and the use of feeding tubes for nutritional support involve complex ethical considerations related to patient care and end-of-life decisions, which are commonly deliberated by ethics committees. However, nonpayment of bills is a financial matter and falls outside the typical scope of ethics committees' functions.
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