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. While performing wound care to a donor skin graft site, the nurse notes some scabbing at the edges and a black collection of blood. What is the nurse's next action?
- A. Leave the scabbed area alone and apply extra ointment
- B. Notify the physician
- C. Gently remove the debris and re-dress the wound
- D. Apply skin softening lotion for 3 hours and then re-dress
Correct answer: C
Rationale: When the nurse notes scabbing at the edges and a black collection of blood, it indicates the presence of debris that needs to be addressed. Leaving the scabbed area alone and applying extra ointment may not address the underlying issue and could lead to complications. Notifying the physician is important in some cases, but immediate action is required to prevent infection in this situation. Gently removing the debris and re-dressing the wound is the correct course of action to promote healing and prevent complications.
3. Erythropoietin used to treat anemia in clients with renal failure should be given in conjunction with:
- A. iron, folic acid, and B12.
- B. an increase in protein in the diet.
- C. vitamins A and C.
- D. an increase in calcium in the diet.
Correct answer: A
Rationale: Erythropoietin is necessary for red blood cell (RBC) production, and in clients with renal failure who lack endogenous erythropoietin, exogenous erythropoietin is administered. However, for erythropoietin to effectively stimulate RBC production, adequate levels of iron, folic acid, and vitamin B12 are crucial. These nutrients are essential for RBC synthesis and maturation. Therefore, the correct answer is to give iron, folic acid, and B12 with erythropoietin. Choice B, an increase in protein in the diet, is not necessary for RBC production and may exacerbate uremia in clients with renal failure. Choices C and D, vitamins A and C, and an increase in calcium in the diet, respectively, are not directly related to RBC production and are not required to enhance the effectiveness of erythropoietin.
4. A healthcare professional is reviewing a patient's arterial blood gas values. Which of the following conditions apply under the following values? pH- 7.49 Bicarbonate ion 24 mEq/dl PaCO2 - 31 mmHg PaO2 - 52 mmHg FiO2 - 0.22
- A. respiratory acidosis
- B. respiratory alkalosis
- C. metabolic acidosis
- D. metabolic alkalosis
Correct answer: B
Rationale: The given blood gas values indicate respiratory alkalosis. A high pH and low PaCO2 level are consistent with respiratory alkalosis. In this scenario, no compensation for the alkalosis is noted, ruling out metabolic acidosis or alkalosis. Metabolic conditions would usually involve changes in bicarbonate levels, which remain within the normal range in this case.
5. How can a diet high in fiber content benefit an individual?
- A. aid in weight loss.
- B. reduce diabetic ketoacidosis.
- C. lower cholesterol.
- D. reduce the need for folate.
Correct answer: C
Rationale: A diet high in fiber content can help lower cholesterol levels by reducing the absorption of cholesterol in the bloodstream. Fiber-rich foods, like grains, apples, potatoes, and beans, can aid in this process. While fiber can aid in weight loss by promoting a feeling of fullness and aiding digestion, it is not primarily for fast weight loss. Fiber does not directly reduce the risk of diabetic ketoacidosis, which is more related to managing blood sugar levels through insulin therapy and dietary control. Folate is a B vitamin that is essential for various bodily functions and is not influenced by fiber intake. Therefore, the correct answer is to lower cholesterol, as fiber plays a significant role in this benefit.
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