NCLEX-PN
Quizlet NCLEX PN 2023
1. A client had a colostomy done one day ago. Which of the following is an abnormal finding when assessing the stoma?
- A. mild edema
- B. minimal bleeding
- C. rose color
- D. dark red color
Correct answer: D
Rationale: A dark red color is an abnormal finding when assessing the stoma as it indicates inadequate blood supply, possibly due to ischemia. Mild edema, minimal bleeding, and a rose color are expected findings one day post colostomy surgery. Mild edema can be present due to tissue trauma and inflammation, minimal bleeding can occur initially, and a healthy stoma typically appears pink to red, known as a rose color, indicating good blood supply and tissue perfusion. Therefore, the dark red color is the abnormal finding in this scenario.
2. Which physiologic mechanism best describes the function of the sodium-potassium pump?
- A. active transport
- B. diffusion
- C. filtration
- D. osmosis
Correct answer: A
Rationale: Active transport is the correct answer as it accurately describes the process involved in the sodium-potassium pump. The pump utilizes energy to move ions against their concentration gradient, maintaining cellular concentrations. Diffusion (choice B) is a passive process where substances move from an area of higher concentration to lower concentration. Filtration (choice C) involves the movement of solutes based on pressure gradients. Osmosis (choice D) is the movement of water across a semipermeable membrane.
3. During a home health visit, a nurse consults with a male patient diagnosed with CAD and COPD who is taking Ventolin, Azmacort, Aspirin, and Theophylline and complains of upset stomach, nausea, and discomfort. What should the nurse do?
- A. Contact the patient's physician immediately
- B. Recommend the patient lie on his right side
- C. Advise the patient to schedule a doctor's visit the next day
- D. Suggest holding the drug Azmacort
Correct answer: A
Rationale: The correct answer is to contact the patient's physician immediately. The patient's symptoms of upset stomach, nausea, and discomfort could indicate theophylline toxicity, a potentially serious condition. It is crucial to consult the physician promptly to address this issue. Option B, recommending the patient lie on his right side, is incorrect as it does not address the potential theophylline toxicity and is not a priority. Option C, advising the patient to schedule a doctor's visit the next day, is inappropriate as the symptoms may indicate an urgent concern. Option D, suggesting holding the drug Azmacort, is incorrect as it does not address the potential theophylline toxicity and should not be done without consulting the physician first.
4. A healthcare professional is assessing a patient in the rehab unit during shift change. The patient has sustained a TBI 3 weeks ago. Which of the following is the most distinguishing characteristic of a neurological disturbance?
- A. LOC (level of consciousness)
- B. Short-term memory
- C. Babinski sign
- D. Clonus sign
Correct answer: A
Rationale: Level of consciousness (LOC) is the most crucial indicator of impaired neurological function. Changes in LOC can signify various neurological conditions, including traumatic brain injury. Short-term memory, while important, is not the most distinguishing characteristic of neurological disturbances. Babinski and Clonus signs are specific neurological tests that can provide information about upper motor neuron lesions but are not as generalizable as changes in LOC for assessing overall neurological status.
5. In Parkinson's disease, a client's difficulty in performing voluntary movements is known as:
- A. Akinesia.
- B. Dyskinesia.
- C. Chorea.
- D. Dystonia.
Correct answer: C.
Rationale: In Parkinson's disease, the client's difficulty in performing voluntary movements is termed dyskinesia. Dyskinesia refers to the impairment of the ability to execute voluntary muscle movements. Akinesia, on the other hand, refers to the absence or lack of voluntary movement. Chorea is characterized by involuntary, rapid, irregular movements. Dystonia involves sustained muscle contractions resulting in abnormal postures or twisting movements. Therefore, dyskinesia is the specific term used for the described difficulty in Parkinson's disease.
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