NCLEX-PN
NCLEX PN Exam Cram
1. When placing an IV line in a patient with active TB and HIV, which safety equipment should the nurse wear?
- A. Sterile gloves, mask, and goggles
- B. Surgical cap, gloves, mask, and proper shoewear
- C. Double gloves, gown, and mask
- D. Goggles, mask, gloves, and gown
Correct answer: D
Rationale: When dealing with a patient with active TB and HIV, the nurse should wear goggles, a mask, gloves, and a gown to protect themselves from potential exposure to infectious agents through respiratory secretions or blood. Surgical cap and proper shoewear are not specifically required for this procedure, making option B incorrect. Double gloving is not necessary in this scenario, hence option C is incorrect. Therefore, the correct choice is D as it includes all the essential protective equipment for this situation.
2. Teaching about the need to avoid foods high in potassium is most important for which client?
- A. a client receiving diuretic therapy
- B. a client with an ileostomy
- C. a client with metabolic alkalosis
- D. a client with renal disease
Correct answer: D
Rationale: Clients with renal disease are predisposed to hyperkalemia and should avoid foods high in potassium. High potassium levels can further burden the kidneys and worsen the condition. Choices A, B, and C are incorrect because clients receiving diuretic therapy, with an ileostomy, or with metabolic alkalosis are at risk for hypokalemia, which is low potassium levels. Therefore, these clients should actually be encouraged to eat foods high in potassium to maintain adequate levels and prevent complications associated with hypokalemia.
3. Which of the following organs of the digestive system has a primary function of absorption?
- A. stomach
- B. pancreas
- C. small intestine
- D. gallbladder
Correct answer: C
Rationale: The small intestine is the correct answer. It is the primary organ responsible for absorption in the digestive system. The stomach's primary function is to break down food through mechanical and chemical digestion. The pancreas produces digestive enzymes to aid in the breakdown of food. The gallbladder stores bile produced by the liver, which helps in the digestion of fats. However, neither the stomach, pancreas, nor gallbladder play the primary role of absorption in the digestive process, making them incorrect choices.
4. A central venous pressure reading of 11cm/H(2)O of an IV of normal saline is determined by the nurse caring for the patient. The patient has a diagnosis of pericarditis. Which of the following is the most applicable?
- A. The patient has a condition of hypovolemia.
- B. Not enough fluid has been given to the patient.
- C. Pericarditis may cause pressures greater than 10cm/H(2)O with testing of CVP.
- D. The patient may have a condition of arteriosclerosis.
Correct answer: C
Rationale: A central venous pressure reading above 10cm/H(2)O may indicate a condition of pericarditis, as the inflammation and fluid accumulation around the heart can lead to elevated pressures. Choices A, B, and D are incorrect. Hypovolemia would typically result in lower CVP readings, not higher. Not enough fluid given would also lead to lower CVP levels. Arteriosclerosis is not directly related to CVP readings in the context of pericarditis.
5. Which of the following nursing diagnoses is most appropriate for the client experiencing acute pancreatitis?
- A. Confusion
- B. Latex Allergy
- C. Acute Pain
- D. Constipation
Correct answer: C
Rationale: Acute Pain is the most appropriate nursing diagnosis for a client experiencing acute pancreatitis because it is a common symptom associated with this condition. Pancreatitis often presents with severe abdominal pain that may radiate to the back. Confusion, Latex Allergy, and Constipation are not typically associated with acute pancreatitis. Confusion may occur in severe cases of pancreatitis with complications, but acute pain is the priority nursing diagnosis due to its prevalence and impact on the client's well-being.
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