NCLEX-PN
NCLEX PN Exam Cram
1. A healthcare professional is reviewing a patient's ECG report. The patient exhibits a flat T wave, depressed ST segment, and short QT interval. Which of the following medications can cause all of the above effects?
- A. Morphine
- B. Atropine
- C. Procardia
- D. Digitalis
Correct answer: D
Rationale: The correct answer is Digitalis. Digitalis is known to cause a flat T wave, depressed ST segment, and a short QT interval on an ECG report. These ECG changes are characteristic of digitalis toxicity. Morphine is not typically associated with these ECG changes. Atropine is more commonly linked to increasing heart rate rather than causing these specific ECG abnormalities. Procardia is a calcium channel blocker that does not typically produce the described ECG findings. Therefore, Digitalis is the most likely medication causing these effects in the patient.
2. A patient has experienced a severe third-degree burn to the trunk in the last 36 hours. Which phase of burn management is the patient in?
- A. Shock phase
- B. Emergent phase
- C. Healing phase
- D. Wound proliferation phase
Correct answer: A
Rationale: The correct answer is A: Shock phase. The shock phase occurs within the first 24-48 hours of burn management. During this phase, the focus is on stabilization, fluid resuscitation, and monitoring for potential complications. Choice B, the Emergent phase, is incorrect as it refers to the initial phase of burn care immediately after the injury. Choice C, the Healing phase, occurs later in the treatment process when the wound starts to repair itself. Choice D, the Wound proliferation phase, is not a recognized phase in burn management.
3. When planning care for a client taking Heparin, which nursing diagnosis should the nurse address first?
- A. Ineffective tissue perfusion related to the presence of a thrombus obstructing blood flow
- B. Risk for injury related to active loss of blood from the vascular space
- C. Deficient knowledge related to the client's lack of understanding of the disease process
- D. Impaired skin integrity related to the development of bruises and/or hematoma
Correct answer: B
Rationale: The correct answer is 'Risk for injury related to active loss of blood from the vascular space.' When a client is taking Heparin, the primary concern is the risk of bleeding due to its anticoagulant properties. Monitoring for signs of active blood loss is crucial to prevent complications like hemorrhage. While ineffective tissue perfusion, deficient knowledge, and impaired skin integrity are important, they are secondary to the immediate risk of bleeding in clients taking anticoagulants like Heparin.
4. A patient has just been prescribed Minipress to control hypertension. The nurse should instruct the patient to be observant of the following:
- A. Dizziness and light-headed sensations
- B. Weight gain
- C. Sensory changes in the lower extremities
- D. Fatigue
Correct answer: A
Rationale: The correct answer is 'Dizziness and light-headed sensations.' Minipress, a medication used to control hypertension, can cause hypotension as a side effect. Dizziness and light-headed sensations are common symptoms of hypotension. Weight gain, sensory changes in the lower extremities, and fatigue are not typically associated with Minipress or hypertension management. Therefore, they are incorrect choices.
5. 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.
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