NCLEX NCLEX-PN
NCLEX PN 2023 Quizlet
1. A high school nurse observes a 14-year-old female rubbing her scalp excessively in the gym. What is the most appropriate course of action for the nurse?
- A. Request the female’s parents for a private evaluation of her scalp
- B. Contact the female’s parents regarding the observations
- C. Observe the hairline and scalp for possible signs of lice
- D. Inform the student’s physician about the situation
Correct answer: C
Rationale: The most appropriate course of action for the nurse is to observe the hairline and scalp for possible signs of lice. The student's behavior of excessively rubbing her scalp raises concerns about a potential infestation, making it necessary to look for signs firsthand. Contacting the parents or the physician should be considered after observing for signs of lice to provide more information and take appropriate action. Requesting a private evaluation from the parents may not be required initially, as lice infestation is a common concern among children and observing for signs is the immediate step to address the situation.
2. Due to a high census, it has been necessary for a number of clients to be transferred to other units within the hospital. Which client should be transferred to the postpartum unit?
- A. A 66-year-old female with gastroenteritis
- B. A 40-year-old female with a hysterectomy
- C. A 27-year-old male with severe depression
- D. A 28-year-old male with ulcerative colitis
Correct answer: A 40-year-old female with a hysterectomy
Rationale: The best client to transfer to the postpartum unit is the 40-year-old female with a hysterectomy. The nurses on the postpartum unit will be knowledgeable about postoperative care and can manage any complications related to the surgery. Choices A and D would be more appropriately cared for on a medical-surgical unit due to their conditions. Choice C should be transferred to a psychiatric unit for specialized care related to severe depression.
3. While undergoing fetal heart monitoring, a pregnant Native-American woman requests that a medicine woman be present in the examination room. Which of the following is an appropriate response by the nurse?
- A. “I will assist you in arranging to have a medicine woman present.”
- B. “We do not allow medicine women in exam rooms.”
- C. “That does not make any difference in the outcome.”
- D. “It is old-fashioned to believe in that.”
Correct answer: “I will assist you in arranging to have a medicine woman present.”
Rationale: The correct response is to show cultural awareness and respect the client's request by offering assistance in arranging for the medicine woman to be present. This approach acknowledges the importance of cultural beliefs and practices in the client's care, fostering trust and cooperation. Choices B, C, and D are inappropriate as they dismiss or belittle the client's cultural beliefs, showing insensitivity and lack of respect, which can negatively impact the nurse-client relationship.
4. To determine the standards of care for the institution, the nurse should consult?
- A. Organizational Chart
- B. Personnel policies
- C. Policies and procedure manual
- D. Job descriptions
Correct answer: Policies and procedure manual
Rationale: The correct answer is the 'Policies and procedure manual.' This manual outlines the policies and procedures that govern patient care within the institution, including the standards of care that healthcare providers are expected to follow. Consulting the policies and procedure manual ensures that the nurse is adhering to the established guidelines and protocols. Choices A, B, and D are incorrect because although they are important documents within an institution, they do not specifically define the standards of care for patient management. The organizational chart illustrates the hierarchy of the institution, personnel policies outline rules related to employees, and job descriptions detail specific roles and responsibilities, none of which directly define patient care standards.
5. Which system is primarily affected by tuberculosis (Mycobacterium)?
- A. stomach (GI)
- B. heart (cardiac)
- C. lungs (respiratory)
- D. skin (integumentary)
Correct answer: C
Rationale: Tuberculosis, caused by Mycobacterium tuberculosis, primarily affects the respiratory system. This aerobic bacillus thrives in highly oxygenated body sites, such as the lungs, growing ends of bones, and the brain. The bacillus is airborne, making the lungs a common site for infection. Choices A, B, and D are incorrect as tuberculosis predominantly impacts the respiratory system and rarely involves the stomach, heart, or skin.
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