NCLEX-PN
Nclex Practice Questions 2024
1. The nurse who was not promoted then went to the utility room and slammed several cupboard doors while looking for Kleenex. This behavior exemplifies:
- A. displacement.
- B. sublimation
- C. conversion.
- D. reaction formation.
Correct answer: A.
Rationale: Displacement unconsciously transfers emotions associated with a person, object, or situation to another less threatening person, object, or situation. In this scenario, the nurse slammed doors instead of expressing anger towards the promoted nurse or the administrator who made the promotion decision. Sublimation is the unconscious process of substituting constructive activity for unacceptable impulses. Since slamming cupboard doors is not a constructive activity, this choice is incorrect. Conversion involves transforming anxiety into physical symptoms, which is not demonstrated in the given behavior. Reaction formation keeps unacceptable feelings or behaviors out of awareness by displaying the opposite feeling or behavior, which is not the case here.
2. A nurse is teaching the mother of an 11-month-old infant how to clean the infant's teeth. The nurse tells the mother to take which action?
- A. Use a small amount of toothpaste and a soft-bristle toothbrush
- B. Use water and a cotton swab and rub the teeth
- C. Use diluted fluoride and rub the teeth with a soft washcloth
- D. Dip the infant's pacifier in maple syrup so that the infant will suck
Correct answer: C
Rationale: The correct action when cleaning an infant's teeth is to use water and a cotton swab to gently rub the teeth. This method helps in removing any food particles or plaque buildup without the risks associated with toothpaste ingestion. Using a small amount of toothpaste and a soft-bristle toothbrush is not recommended for infants as they may swallow the toothpaste, leading to potential fluoride ingestion issues. Using diluted fluoride and rubbing the teeth with a soft washcloth is unnecessary at this age since infants typically receive fluoride through other sources like formula. Dipping the infant's pacifier in maple syrup is highly inappropriate and poses a significant risk of tooth decay due to the high sugar content, which can harm the infant's teeth.
3. A 6-month-old client is admitted with possible intussusception. Which question during the nursing history is least helpful in obtaining information regarding this diagnosis?
- A. "Tell me about his pain."?
- B. "What does his vomit look like?"?
- C. "Describe his usual diet."?
- D. "Have you noticed changes in his abdominal size?"?
Correct answer: C
Rationale: The least helpful question in obtaining information regarding intussusception is "Describe his usual diet."? This question is least relevant to the specific symptoms and presentation of intussusception. Choices A, B, and D are more directly related to symptoms commonly associated with intussusception and can provide important diagnostic clues. Asking about pain, vomit appearance, and changes in abdominal size can help in assessing the severity and progression of the condition, making them more crucial questions to ask in this scenario. Pain is a cardinal symptom of intussusception, changes in vomit appearance may indicate gastrointestinal issues, and alterations in abdominal size can signify the presence of a mass or obstruction, all of which are pertinent in diagnosing and managing intussusception.
4. Upon arrival at the emergency room, the client presents with severe burns to the left arm, hands, face, and neck. What action should take priority?
- A. Starting an IV
- B. Applying oxygen
- C. Obtaining blood gases
- D. Medicating the client for pain
Correct answer: B
Rationale: In a client with severe burns to the face and neck, airway assessment and supplemental oxygen are crucial. Therefore, applying oxygen is the priority to ensure adequate oxygenation for the client. This intervention takes precedence over other actions to stabilize the client's condition. Starting an IV for fluid resuscitation is the next appropriate step following ensuring oxygenation (Choice A). While pain management is important, it is a secondary priority after ensuring oxygenation and fluid resuscitation, making medicating the client for pain a later intervention (Choice D). Obtaining blood gases (Choice C) is not the immediate priority in this scenario and would typically be ordered by the healthcare provider based on the client's condition and response to initial interventions.
5. The licensed practical nurse assigned to the postpartum unit is preparing to administer Rhogam to a postpartum client. Which woman is not a candidate for RhoGam?
- A. A gravida IV para 3 that is Rh negative with an Rh-positive baby
- B. A gravida I para 1 that is Rh negative with an Rh-positive baby
- C. A gravida II para 0 that is Rh negative admitted after a stillbirth delivery
- D. A gravida IV para 2 that is Rh negative with an Rh-negative baby
Correct answer: D
Rationale: The mothers in answers A, B, and C all require RhoGam as they are Rh negative with an Rh-positive baby or have experienced a stillbirth delivery, making them candidates for RhoGam injection. The mother in answer D is the only one who does not require Rhogam because she is Rh negative with an Rh-negative baby, eliminating the need for RhoGam administration.
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