NCLEX NCLEX-PN
Quizlet NCLEX PN 2023
1. A 32-year-old male with a complaint of dizziness has an order for Morphine via IV. What should the nurse do first?
- A. Check the patient’s chest x-ray results.
- B. Retake vitals including blood pressure.
- C. Perform a neurological screening on the patient.
- D. Request the physician on-call to assess the patient.
Correct answer: Retake vitals including blood pressure.
Rationale: The correct first action for the nurse to take in this situation is to retake the patient's vitals, including blood pressure. Dizziness can be a sign of hypotension, which may be a contraindication for administering Morphine. Checking the chest x-ray results (Choice A) would not be the priority in this case as addressing the dizziness is more urgent. Performing a neurological screening (Choice C) may be important but not the first step when a patient presents with dizziness and an order for Morphine. Requesting the physician to assess the patient (Choice D) should come after the initial assessment and vitals retake.
2. What is most likely to impact the body image of an infant newly diagnosed with Hemophilia?
- A. immobility
- B. altered growth and development
- C. hemarthrosis
- D. altered family processes
Correct answer: altered family processes
Rationale: Altered Family Processes play a significant role in impacting the body image of an infant newly diagnosed with Hemophilia. Infants are highly perceptive of their caregivers' responses, and any changes in family dynamics due to the diagnosis can affect the infant's sense of security and trust, influencing their body image and self-perception. Immobility, while a long-term effect of hemophilia, is not an immediate impact on body image. Altered growth and development would not have manifested immediately post-diagnosis. Hemarthrosis, characterized by bleeding into joint spaces, is a hallmark of hemophilia but does not directly influence body image in the immediate aftermath of a new diagnosis.
3. When are pressure ulcers most likely to occur?
- A. when clients are left in one position in bed for extended periods of time.
- B. when clients are underweight.
- C. when clients are overweight.
- D. only in underweight and overweight clients.
Correct answer: when clients are left in one position in bed for extended periods of time.
Rationale: Pressure ulcers usually occur over bony prominences and are caused by decreased circulation. The client who is left in one position in bed for extended periods of time is more prone to decreased circulation to an area of the body and to acquiring a pressure ulcer. Choices B and C are incorrect as pressure ulcers are not exclusive to underweight or overweight clients. The key factor is prolonged pressure on the skin, not the weight of the client. Therefore, the correct answer is that pressure ulcers are most likely to occur when clients are immobilized in one position for extended periods of time.
4. A patient 3 hours post-op from a hysterectomy is complaining of intense pain at the incision site. When assessing the patient, the nurse notes a BP of 169/93, pulse 145 bpm, and regular. What action should the nurse take?
- A. Reassure the patient that pain is normal following surgery.
- B. Administer prn Nifedipine and assess the client’s response.
- C. Administer prn Meperidine HCL and assess the client’s response.
- D. Recheck BP and pulse rate every 20 minutes for the next hour.
Correct answer: Administer prn Meperidine HCL and assess the client’s response.
Rationale: The correct action for the nurse to take in this situation is to administer prn Meperidine HCL and assess the client's response. A BP of 169/93 and a pulse of 145 bpm indicate pain-related hypertension and sinus tachycardia, which are physiological responses to pain. Treating the cause of the increased pulse rate requires pain medication. Reassuring the patient about normal post-surgery pain is important, but addressing the physiological responses to pain is a priority. Administering Nifedipine, a calcium channel blocker, is not indicated for pain management but for hypertension. Rechecking the BP and pulse rate without addressing the pain directly does not address the underlying issue causing the elevated vital signs.
5. The nurse, assisting with data collection of the abdomen, inspects the client’s abdomen. Which assessment technique should the nurse perform next?
- A. Percussion
- B. Auscultation
- C. Light palpation
- D. Deep palpation
Correct answer: B
Rationale: The correct answer is auscultation. The assessment techniques used for a physical examination are inspection, palpation, percussion, and auscultation. These techniques are normally performed in this order. However, in the abdominal examination, auscultation is performed after inspection and before palpation and percussion. This order is specific to the abdomen because palpation and percussion can increase peristalsis, leading to a false interpretation of bowel sounds. Therefore, auscultation is performed before palpation and percussion in abdominal assessments to ensure accurate bowel sound assessment. Percussion and palpation are performed after auscultation in abdominal assessments. Choices A, C, and D are incorrect as auscultation is the next assessment technique to perform after inspection in abdominal assessments, followed by palpation and percussion.
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