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 3-day post-operative client with a Left Knee Replacement is complaining of being chilled and nauseated. Her TPR is 100.4-94-28 and Blood Pressure is 146/90. What is the nurse's best action?
- A. Call the surgeon immediately.
- B. Administer Extra Strength Tylenol per orders.
- C. Assess the surgical site.
- D. Offer extra blankets and increase fluids.
Correct answer: A
Rationale: The correct answer is to call the surgeon immediately. The client's symptoms of being chilled and nauseated, along with an elevated temperature (100.4�F), could indicate an infection following the knee replacement surgery. In this scenario, prompt action is crucial to prevent any potential complications. Calling the surgeon allows for further assessment, possible diagnostic tests, and appropriate interventions to be initiated. Administering Tylenol or offering blankets and fluids may temporarily alleviate symptoms but do not address the underlying issue of a potential infection. Assessing the surgical site is important but not as urgent as involving the surgeon in this situation.
3. A 13-year-old girl is admitted to the ER with lower right abdominal discomfort. What should the admitting nurse do first?
- A. Administer Loritab to the patient for pain relief.
- B. Place the patient in a right sidelying position for pressure relief.
- C. Start a Central Line.
- D. Provide pain reduction techniques without administering medication.
Correct answer: D
Rationale: In a case of lower right abdominal discomfort, the first step should be to provide pain reduction techniques without administering medication. Administering pain medication or starting a central line should not be done without medical orders. Placing the patient in a right sidelying position may help with pressure relief, but addressing pain reduction techniques without medication is the initial priority in this scenario. It is essential to assess the patient further, consult with a healthcare provider, and follow the appropriate protocols before administering any medication or invasive procedures like starting a central line.
4. A 20-year-old obese female client is preparing to have gastric bypass surgery for weight loss. She says to the nurse, "I need this surgery because nothing else I have done has helped me to lose weight."? Which response by the nurse is most appropriate?
- A. "If you eat less, you can save some money."?
- B. "Exercise is a healthier way to lose weight."?
- C. "You should try the Atkins diet first."?
- D. "I respect your decision to choose surgery."?
Correct answer: D
Rationale: The most appropriate response by the nurse is to show respect and empathy towards the client's decision. Option D acknowledges the client's autonomy and decision-making process, fostering a therapeutic relationship. Options A, B, and C are insensitive and unprofessional. Option A implies a financial incentive for weight loss, which can be perceived as disrespectful and trivializing the client's concerns. Option B suggests an alternative method without considering the client's reasons for choosing surgery, potentially invalidating her experiences. Option C recommends a specific diet without addressing the client's concerns or choices, neglecting her autonomy in decision-making.
5. How can the nurse promote relief of muscle pain, spasms, and tension?
- A. Encouraging the client to continue their activities as usual.
- B. Immobilizing the client.
- C. Applying heat, cold, pressure, or vibration to the painful area.
- D. Administering pain medication as needed to ease the muscle.
Correct answer: C
Rationale: To promote relief of muscle pain, spasms, and tension, the nurse should consider applying heat, cold, pressure, or vibration to the painful area. These interventions can help alleviate pain associated with muscle tension, pain, or spasms. Choice A is incorrect because encouraging the client to continue their activities as usual may exacerbate the pain. Choice B is incorrect as immobilizing the client may not address the underlying issue and could potentially lead to further complications. Choice D is also incorrect because while pain medication can be used, it is not the first-line treatment for muscle pain, spasms, and tension.
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