NCLEX-PN
NCLEX PN Exam Cram
1. Which type of cells secrete insulin?
- A. alpha cells
- B. beta cells
- C. CD4 cells
- D. helper cells
Correct answer: B
Rationale: Beta cells are responsible for secreting insulin. Insulin is produced by beta cells in the pancreas and plays a crucial role in regulating blood sugar levels. Alpha cells secrete glucagon, not insulin (Choice A). CD4 cells are a type of immune cell that helps coordinate the immune response (Choice C). Helper cells are a type of immune cell that aids in activating other immune cells (Choice D). Therefore, the correct answer is beta cells.
2. A client had a Caesarean delivery and is postpartum day 1. She asks for pain medication when the nurse enters the room to do her shift assessment. The client states that her pain level is an 8 on a scale of 1 to 10. What should be the nurse's priority of care?
- A. Give the pain medication and return in an hour for further assessment to allow time for the medication to work.
- B. Complete the postpartum assessment and then give the client pain medication.
- C. Give the pain medication first, do a quick assessment while administering the medication to ensure the pain is not caused by a complication, and return for the full assessment after the client's pain has subsided.
- D. Instruct the patient to do relaxation exercises to relieve her discomfort.
Correct answer: C
Rationale: Pain management is a priority, so the nurse should immediately provide pain medication. However, the nurse should conduct a quick assessment while administering the medication to ensure that a complication, such as hemorrhage, hasn't caused the increased pain. A complete assessment can wait until the pain subsides. Controlling pain will enable the client to move, eliminating other potential complications of delivery and facilitating bonding with the infant. Relaxation techniques can act as an adjunct therapy but by themselves are not usually effective for pain management during the early post-Caesarean period.
3. The client is admitted with a period of unobserved loss of consciousness and now has an EEG scheduled this morning. What should the nurse implement?
- A. Keep NPO and hold medication.
- B. Hold sedatives, but allow the client to have breakfast and give other medicines.
- C. Administer medications, but hold anticonvulsants.
- D. Give additional fluids and some caffeine prior to the test.
Correct answer: C
Rationale: Prior to an EEG, it is essential for the client to eat to prevent a drop in blood sugar levels. The nurse should hold sedatives but allow the client to have breakfast and administer other necessary medications. Holding sedatives is crucial to ensure accurate EEG results, while providing breakfast helps maintain stable blood sugar levels. Administering other medications, excluding sedatives, is important for the client's overall care. Choices A, C, and D are incorrect because keeping the client NPO and holding medications, administering medications but holding anticonvulsants, and giving additional fluids and caffeine are not appropriate actions before an EEG.
4. The schizophrenic client who is admitted to the hospital for possible bowel obstruction has an NG tube and complains of pain. What should the nurse do at this time?
- A. Decrease the stimuli and observe frequently
- B. Administer the PRN sedative
- C. Call the physician immediately
- D. Administer the PRN pain medication
Correct answer: D
Rationale: In this scenario, the nurse should administer the PRN (as needed) pain medication to address the schizophrenic client's complaint of pain. It is essential to provide relief and comfort to the client experiencing pain. Option A, decreasing stimuli and observing frequently, may not address the underlying cause of pain and delay relief. Option B, administering a sedative, does not target the pain but may mask symptoms. Option C, calling the physician immediately, while important in some situations, is not the most immediate action needed to alleviate the client's pain. Therefore, the most appropriate action at this time is to administer the PRN pain medication to help alleviate the client's discomfort.
5. The client is cared for by a nurse and calls for the nurse to come to the room, expressing feeling unwell. The client's vital signs are BP: 130/88, HR: 102, RR: 28. What should the nurse do next?
- A. Administer PRN anxiolytic
- B. Administer Antibiotics
- C. Reassure the client that everything is okay and offer food and beverage
- D. Determine the Glasgow Coma Scale
Correct answer: A
Rationale: Correct! The client's vital signs indicate tachycardia and tachypnea, which could be indicative of hypoxia. Administering a PRN anxiolytic would not address the underlying issue and could mask deterioration. Reassuring the client without further assessment or intervention could lead to a delay in appropriate care if there is a serious underlying cause for the symptoms. Determining the Glasgow Coma Scale is not relevant to the client's presenting symptoms of feeling unwell and suspecting something is wrong, coupled with abnormal vital signs.
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