NCLEX NCLEX-PN
2024 Nclex Questions
1. The child with seizure disorder is being treated with Dilantin (phenytoin). Which of the following statements by the patient’s mother indicates to the nurse that the patient is experiencing a side effect of Dilantin therapy?
- A. “She is very irritable lately.”
- B. “She sleeps quite a bit of the time.”
- C. “Her gums look too big for her teeth.”
- D. “She has gained about 10 pounds in the last 6 months.”
Correct answer: “Her gums look too big for her teeth.”
Rationale: The correct answer is '“Her gums look too big for her teeth.”' Hyperplasia of the gums is a known side effect associated with Dilantin therapy. Option A, '“She is very irritable lately,”' is not a typical side effect of Dilantin. Option B, '“She sleeps quite a bit of the time,”' is a common side effect of Dilantin but not specific to gum hyperplasia. Option D, '“She has gained about 10 pounds in the last 6 months,”' is not typically associated with Dilantin therapy and is unrelated to the question.
2. Which nurse should be assigned to care for the postpartal client with preeclampsia?
- A. The nurse with 2 weeks of experience on the postpartum unit
- B. The nurse with 3 years of experience in labor and delivery
- C. The nurse with 10 years of experience in surgery
- D. The nurse with 1 year of experience in the neonatal intensive care unit
Correct answer: The nurse with 3 years of experience in labor and delivery
Rationale: The nurse with 3 years of experience in labor and delivery (answer B) should be assigned to care for the postpartal client with preeclampsia. This nurse has the most relevant experience and knowledge of possible complications associated with preeclampsia due to their background in labor and delivery. Assigning a nurse with only 2 weeks of experience on the postpartum unit (answer A) would not be suitable for handling the complexities of caring for a client with preeclampsia. Nurses with experience in surgery (answer C) or the neonatal intensive care unit (answer D) lack the specific expertise needed for managing a postpartal client with preeclampsia, making them unsuitable choices for this assignment.
3. As part of the teaching plan for a client with type I diabetes mellitus, the nurse should include that carbohydrate needs might increase when:
- A. an infection is present.
- B. there is an emotional upset.
- C. a large meal is eaten.
- D. active exercise is performed.
Correct answer: active exercise is performed.
Rationale: During active exercise, insulin sensitivity increases, leading to lower blood glucose levels. To balance the effect of increased insulin sensitivity, additional carbohydrates might be needed. The other choices are incorrect because: A) an infection typically raises blood glucose levels rather than increasing the need for carbohydrates; B) emotional upset can impact blood glucose but does not directly affect carbohydrate needs; C) while a large meal can raise blood glucose levels, it does not necessarily mean an increase in carbohydrate needs.
4. A patient reports, “I tore 3 of my 4 Rotator cuff muscles in the past.” Which of the following muscles cannot be considered as possibly being torn?
- A. Teres minor
- B. Teres major
- C. Supraspinatus
- D. Infraspinatus
Correct answer: Teres major
Rationale: The correct answer is Teres major. The Rotator Cuff consists of Teres Minor, Infraspinatus, Supraspinatus, and Subscapularis muscles, not Teres major. Teres major is not part of the rotator cuff, so it cannot be considered as possibly being torn. The other choices, Teres minor, Supraspinatus, and Infraspinatus, are all part of the Rotator Cuff and could potentially be torn in this patient's case.
5. A nurse notes that an elderly client suddenly does not keep appointments and is not wearing appropriate clothing. Which statement by the client raises the suspicion of financial abuse?
- A. “I am having difficulty paying for this new antibiotic the physician prescribed.”
- B. “I am a little short on cash since my daughter moved in to help me.”
- C. “I have not felt like shopping since the weather has gotten worse.”
- D. “People do not realize how difficult it is to make ends meet on a fixed income.”
Correct answer: “I am a little short on cash since my daughter moved in to help me.”
Rationale: The correct answer is B: “I am a little short on cash since my daughter moved in to help me.” This statement raises suspicion of financial abuse as it suggests a recent change in financial circumstances after the daughter moved in. Financial abuse in elderly clients can be indicated by sudden unexplained financial deficits or changes, such as difficulty paying for necessities despite previously being able to do so. Choices A, C, and D do not directly imply a recent financial change due to external factors, making them less indicative of potential financial abuse. Option B is the most concerning statement that warrants further investigation into possible financial exploitation.
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