NCLEX NCLEX-PN
Nclex 2024 Questions
1. A client with acute leukemia develops a low white blood cell count. In addition to the institution of isolation, the nurse should:
- A. Request that foods be provided in sealed single-serving packages
- B. Ask the client to wear a mask when visitors are present
- C. Prep IV sites with mild soap and water and alcohol
- D. Provide foods in sealed single-serving packages
Correct answer: Provide foods in sealed single-serving packages
Rationale: For a client with acute leukemia and a low white blood cell count, preventing exposure to food contaminants is crucial due to immune suppression. Providing foods in sealed single-serving packages helps reduce the risk of contamination. Choice B is incorrect as it introduces the potential of infection from visitors. Choice A, suggesting disposable utensils, is not as effective as sealed containers in preventing food contamination. Choice C, using alcohol for prepping IV sites, is less suitable due to its drying effect and potential for skin breakdown, making sealed packages a better option for food safety.
2. Following a thyroidectomy, a client is complaining of shortness of breath (SOB) and neck pressure. Which nursing action is the best response?
- A. Stay with the client, remove the dressing, and elevate the head of bed.
- B. Call a code, open the trach set, and position the client supine.
- C. Have the client say “EEE” to check for laryngeal integrity.
- D. Immediately go to the nurse’s station and call the physician
Correct answer: Stay with the client, remove the dressing, and elevate the head of bed.
Rationale: Correct! The client is displaying signs of respiratory distress after a thyroidectomy. By staying with the client, removing the dressing around the neck, and elevating the head of the bed, the nurse can assess the airway and breathing status more effectively. This immediate action can help alleviate any potential airway obstruction. Choice B is incorrect because calling a code and opening the trach set without initial assessment and basic interventions may delay necessary actions. Choice C is incorrect as having the client say “EEE” is not as immediate or effective in addressing the respiratory distress. Choice D is incorrect as leaving the client alone and calling the physician without providing immediate assistance can be detrimental in a situation of potential airway compromise.
3. An adult who had been abused as a child is discussing the group therapy program. Which statement indicates that the client has gained insight?
- A. “I think I was a lonely child because I could not tell anyone about my abuse.”
- B. “I am now aware of how deep-seated my anger is. Before, I did not realize I was angry.”
- C. “The program has given me the courage to tell my mother how I felt about her role in my hurt.”
- D. “There are so many people just like me, who are just normal people that had bad things happen to them.”
Correct answer: “I am now aware of how deep-seated my anger is. Before, I did not realize I was angry.”
Rationale: The correct answer demonstrates insight gained by the client regarding their emotional state. Recognizing deep-seated anger that was previously unrecognized indicates progress in understanding their emotions and the impact of past abuse. Choice A reflects a sense of loneliness due to an inability to share about the abuse, which does not directly address emotional insight. Choice C shows progress in addressing relationships but does not specifically relate to emotional awareness. Choice D acknowledges shared experiences but does not reflect personal emotional growth or insight.
4. When preparing a client for a neck x-ray, what is the most appropriate action for the nurse to take if the client expresses concern about removing a religious medal worn around the neck?
- A. Telling the client that the medal and chain will be kept at the nurse's station for safekeeping while the client is undergoing the x-ray
- B. Asking the client to remove the medal until the x-ray has been completed
- C. Assisting the client in pinning the medal and chain to the waistband of the client's pajama bottoms
- D. Asking the client to place the medal in the top drawer of the bedside stand just before leaving for the radiology department
Correct answer: Assisting the client in pinning the medal and chain to the waistband of the client's pajama bottoms
Rationale: When a client undergoing a neck x-ray expresses concern about removing a religious medal worn around the neck, the nurse should assist the client in pinning the medal and chain to the hospital gown or in another area where it will not appear on the x-ray image. This action allows the client to keep the medal close without interfering with the x-ray procedure. It is important to ensure that the radiology department staff is informed about this arrangement. Asking the client to remove the medal, keeping it at the nurse's station, or placing it in the bedside stand is not appropriate. These actions may lead to the loss of the medal and chain and do not address the client's concerns about the religious significance of the item.
5. The nurse is preparing a client for mammography. To prepare the client for a mammogram, the nurse should tell the client:
- A. To omit creams, powders, or deodorants before the exam
- B. To restrict fat intake for 1 week before the test
- C. That mammography replaces the need for self-breast exams
- D. That mammography requires a higher dose of radiation than an x-ray
Correct answer: To omit creams, powders, or deodorants before the exam
Rationale: The client undergoing a mammogram should be instructed to omit deodorants or powders beforehand because they can interfere with the imaging results. Answer A is correct as it aligns with the preparation needed before a mammogram to ensure accurate results. Answer B is incorrect because there is no requirement for fat intake restrictions before a mammogram. Answer C is incorrect because mammography does not replace the necessity of self-breast exams; both are crucial for maintaining breast health. Answer D is incorrect because a mammogram does not require higher doses of radiation than an x-ray. In fact, mammography uses a low dose of radiation to create images for breast examination.
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