NCLEX NCLEX-PN
NCLEX PN Exam Cram
1. At what age will vision be 20/20 in children?
- A. 4 years old
- B. 5 years old
- C. 6 years old
- D. 7 years old
Correct answer: 6 years old
Rationale: The correct answer is 6 years old. At this age, children typically have the potential for 20/20 vision. This is considered the standard age for achieving optimal vision clarity. Choices A, B, and D are incorrect as they are not typically associated with the age at which children achieve 20/20 vision.
2. A nurse is explaining a nonstress test to a pregnant client. The nurse explains that the results are nonreactive if which finding is noted on the electronic monitoring recording strip?
- A. Two fetal heart accelerations within a 20-minute period, peaking at 15 beats/min above baseline and lasting 15 seconds from baseline to baseline
- B. Accelerations without fetal movement with fetal heart rate (FHR) increases of 15 beats/min for 15 seconds
- C. Acceleration of the FHR by 25 to 30 beats/min for at least 15 seconds in response to fetal movement
- D. Absence of accelerations after fetal movement
Correct answer: Absence of accelerations after fetal movement
Rationale: The correct answer is 'Absence of accelerations after fetal movement.' In a nonreactive (nonreassuring) stress test, the monitor recording would not show accelerations after fetal movement within a 40-minute period. This absence of accelerations indicates a nonreactive result. Choices A, B, and C describe different patterns of fetal heart rate accelerations that are not indicative of a nonreactive result in a nonstress test, making them incorrect. Choice A describes the characteristics of a reactive (reassuring) result, where there should be at least two fetal heart accelerations within a 20-minute period, peaking at least 15 beats/min above the baseline, and lasting 15 seconds from baseline to baseline. Choice B incorrectly states 'Accelerations without fetal movement,' which is contradictory. Choice C describes an acceleration response to fetal movement, which does not signify a nonreactive result.
3. The client asks the nurse not to tell anyone outside of the care team about his positive HIV diagnosis. What response is most appropriate?
- A. “I have to inform all clients on the unit of your diagnosis as it is transmissible.”
- B. “I will not communicate your diagnosis to anyone without your permission.”
- C. “Because this is a communicable disease, it may need to be reported to the CDC.”
- D. “You should not be concerned with who I share your diagnosis with.”
Correct answer: “Because this is a communicable disease, it may need to be reported to the CDC.”
Rationale: The most appropriate response is C: “Because this is a communicable disease, it may need to be reported to the CDC.” It is important to uphold patient confidentiality, but in the case of certain communicable diseases like HIV, there are legal requirements for mandatory reporting to public health authorities such as the CDC. Option A is incorrect because it violates patient confidentiality and does not consider legal obligations. Option B, while respecting the client's wishes, may not align with the legal requirement for reporting certain communicable diseases. Option D is inappropriate as it dismisses the client's concerns and rights regarding their health information.
4. Hormonal agents are used to treat some cancers. An example is:
- A. thyroxine to treat thyroid cancer.
- B. ACTH to treat adrenal carcinoma.
- C. estrogen antagonists to treat breast cancer.
- D. glucagon to treat pancreatic carcinoma.
Correct answer: estrogen antagonists to treat breast cancer.
Rationale: Estrogen antagonists are commonly used to treat estrogen hormone-dependent cancers such as breast carcinoma. One well-known estrogen antagonist used in breast cancer therapy is Tamoxifen (Nolvadex). This drug, in combination with surgery and other chemotherapeutic drugs, reduces breast cancer recurrence by 30%. Estrogen antagonists can also be administered to prevent breast cancer in women who have a strong family history. Thyroxine is a thyroid hormone used to treat hypothyroidism, not thyroid cancer. ACTH is an anterior pituitary hormone that stimulates the adrenal glands to release glucocorticoids; it does not treat adrenal cancer. Glucagon is a pancreatic alpha cell hormone that stimulates glycogenolysis and gluconeogenesis; it does not treat pancreatic cancer.
5. The nurse overhears two nursing students talking about a client in the cafeteria. What should the nurse do first?
- A. Report the incident to the nursing supervisor.
- B. Write up a variance report about the incident.
- C. Instruct the students that this is a violation of HIPAA.
- D. Notify the students’ faculty regarding the violation.
Correct answer: Instruct the students that this is a violation of HIPAA.
Rationale: The correct answer is to instruct the students that discussing a client in a public area like the cafeteria violates HIPAA regulations. This is important to educate the students about patient confidentiality and the consequences of breaching it. Reporting to the nursing supervisor or faculty should come after addressing the students directly. Writing up a variance report is not the immediate action needed in this situation, as educating the students about their mistake should be the priority. It is essential to address the issue at the source by educating the students first rather than escalating the matter to supervisors or faculty immediately.
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