NCLEX-PN
Quizlet NCLEX PN 2023
1. In a client with asthma who develops respiratory acidosis, what should the nurse expect the client's serum potassium level to be?
- A. normal
- B. elevated
- C. low
- D. unrelated to the pH
Correct answer: B
Rationale: In respiratory acidosis, the serum potassium level is expected to be elevated. This occurs because potassium shifts from cells into the bloodstream as a compensatory mechanism to maintain acid-base balance. Choices A, C, and D are incorrect. A normal potassium level is not expected in respiratory acidosis. A low potassium level is more commonly associated with alkalosis, not acidosis. The potassium level is indeed related to pH changes in respiratory acidosis, leading to the expected elevation.
2. A nurse is instructing a patient on the order of sensations with the application of an ice water bath for a swollen right ankle. Which of the following is the correct order of sensations experienced with an ice water bath?
- A. cold, burning, aching, and numbness
- B. burning, aching, cold, and numbness
- C. aching, cold, burning, and numbness
- D. cold, aching, burning, and numbness
Correct answer: A
Rationale: The correct order of sensations experienced with an ice water bath is cold, burning, aching, and numbness, as stated by the acronym CBAN (cold, burn, ache, numbness). Option A is the correct sequence. Choice B is incorrect as it starts with burning, which typically follows the cold sensation. Choice C is incorrect as aching is usually felt after the burning sensation. Choice D is incorrect as aching usually occurs after the burning sensation.
3. A nurse has been ordered to set up Buck's traction on a patient's lower extremity due to a femur fracture. Which of the following applies to Buck's traction?
- A. A weight greater than 10 lbs. should be used.
- B. The line of pull is upward at an angle.
- C. The line of pull is straight
- D. A weight greater than 20 lbs. should be used.
Correct answer: C
Rationale: The correct answer is that the line of pull is straight for Buck's traction. This type of traction is applied to maintain alignment and immobilization of fractures, typically involving the lower extremities. A straight line of pull helps to provide the necessary countertraction to keep the fractured bone in proper alignment. Choices A and D are incorrect because Buck's traction commonly uses a weight range between 5-10 lbs, and using a weight greater than 10 or 20 lbs would not be appropriate or safe. Choice B is incorrect as well since the line of pull for Buck's traction is straight, not upward at an angle.
4. Jane Love, a 35-year-old gravida III para II at 23 weeks gestation, is seen in the Emergency Department with painless, bright red vaginal bleeding. Jane reports that she has been feeling tired and has noticed ankle swelling in the evening. Laboratory tests reveal a hemoglobin level of 11.5 g/dL. After evaluating the situation, the nurse determines that Jane is at risk for placenta previa, based on which of the following data?
- A. anemia
- B. edema
- C. painless vaginal bleeding
- D. fatigue
Correct answer: C
Rationale: Placenta previa is a disorder where the placenta implants in the lower uterine segment, causing painless bleeding in the third trimester of pregnancy. The bleeding results from tearing of the placental villi from the uterine wall as the lower uterine segment contracts and dilates. It can be slight or profuse and can include bright red, painless bleeding. While anemia (choice A) may be a consequence of chronic bleeding from placenta previa, it is not a direct indicator. Edema (choice B) and fatigue (choice D) are nonspecific symptoms that can occur in pregnancy but are not specific to placenta previa.
5. A patient has a history of cardiac arrhythmia. A nurse has been ordered to give 2 units of blood to this patient. The nurse should take which of the following actions?
- A. Administer pain medication to the patient.
- B. Inform the patient's family about the procedure in person.
- C. Decrease the temperature of the blood to be given.
- D. Increase the temperature of the blood to be given.
Correct answer: D
Rationale: In patients with a history of cardiac arrhythmia, warming the blood before transfusion can help prevent additional arrhythmias. Cold blood can lead to arrhythmias and should be avoided. Administering pain medication (Choice A) is not directly related to the safe administration of blood. Informing the patient's family in person (Choice B) is important but not the immediate action required for safe transfusion. Decreasing the temperature of the blood to be given (Choice C) would increase the risk of cardiac arrhythmia, contrary to the goal of ensuring patient safety.
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