NCLEX-PN
NCLEX PN Exam Cram
1. A 27-year-old woman has delivered twins in the OB unit. The patient develops a condition of 5-centimeter diastasis recti abdominis. Which of the following statements is the most accurate when instructing the patient?
- A. Avoid sit-ups to prevent worsening the condition.
- B. Surgery is not always necessary for this condition.
- C. Guarding the abdominal region is important at this time.
- D. Antibiotics are not needed for diastasis recti abdominis.
Correct answer: C
Rationale: After experiencing diastasis recti abdominis, it is crucial for the patient to protect and guard the abdominal region to facilitate healing. Choice A is correct since avoiding sit-ups is important to prevent worsening the condition by increasing intra-abdominal pressure. Choice B is accurate as not all cases of diastasis recti abdominis require surgery; conservative management is often effective. Choice D is also correct as antibiotics are not indicated for diastasis recti abdominis since it is a separation of the abdominal muscles and not an infectious condition.
2. While Fluorouracil (5FUĀ®) is being infused, a client complains of burning at the IV site. What should the nurse do first?
- A. Aspirate the IV site for blood return.
- B. Slow the infusion.
- C. Inspect the IV site.
- D. Stop the infusion.
Correct answer: C
Rationale: The correct first action for the nurse is to inspect the IV site. This is important to assess for any signs of infiltration or extravasation, which could be causing the burning sensation. Aspirating the IV site for blood return (Choice A) may not be the initial priority as it does not directly address the client's complaint of burning. Slowing the infusion (Choice B) may help alleviate discomfort but should not be done before inspecting the site. Stopping the infusion (Choice D) may be necessary, but inspecting the site should come first to determine the appropriate course of action.
3. A client receives a cervical intracavity radium implant as part of her therapy. A common side effect of a cervical implant is:
- A. creamy, pink-tinged vaginal drainage.
- B. stomatitis.
- C. constipation.
- D. xerostomia.
Correct answer: A
Rationale: The correct answer is 'creamy, pink-tinged vaginal drainage.' This side effect persists for 1 to 2 months after the removal of a cervical implant. Diarrhea, not constipation, is usually a side effect of cervical implants. Stomatitis and xerostomia are local side effects of radiation to the mouth, not associated with cervical implants. Therefore, choices B, C, and D are incorrect.
4. A nurse is assigned to do pre-operative teaching on a blind patient who is scheduled for surgery the following morning. What teaching strategy would best fit the situation?
- A. Verbal teaching in short sessions throughout the day
- B. Provide a pre-operative booklet in Braille
- C. Provide an audio recording for the client
- D. Have the blind patient's family member assist with the instruction
Correct answer: A
Rationale: For a blind patient scheduled for surgery the following morning, the best teaching strategy would be verbal teaching in short sessions throughout the day. Providing information in smaller amounts makes it easier to retain, and one-on-one teaching is most effective. Choice B, providing a pre-operative booklet in Braille, may not be as practical for last-minute teaching. Choice C, providing an audio recording, may not allow for immediate interaction and clarification. Choice D, having a family member instruct the patient, may not ensure the accuracy and clarity of the information provided.
5. A patient has recently been prescribed Norvasc. Which of the following side effects should the patient specifically watch out for?
- A. Hypotension and Angina
- B. Hypertension
- C. Lower extremity edema
- D. Peripheral sensory loss and SOB
Correct answer: A
Rationale: The correct answer is 'Hypotension and Angina.' Norvasc is a medication known to cause hypotension (low blood pressure) and angina (chest pain) as side effects. These side effects are important for the patient to watch out for as they can indicate potential issues related to the medication. Choice B ('Hypertension') is incorrect as Norvasc is actually used to treat hypertension, not cause it. Choice C ('Lower extremity edema') is not a common side effect of Norvasc. Choice D ('Peripheral sensory loss and SOB') is not typically associated with Norvasc's side effects.
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