NCLEX NCLEX-PN
NCLEX PN Exam Cram
1. A nurse is working in a pediatric clinic, and a 25-year-old mother comes in with a 4-week-old baby. The mother is stressed out about the loss of sleep, and the baby exhibits signs of colic. Which of the following techniques should the nurse teach the mother?
- A. Distraction of the infant with a red object
- B. Prone positioning techniques
- C. Tapping reflex techniques
- D. Neural warmth techniques
Correct answer: Neural warmth techniques
Rationale: Neural warmth techniques involve the caregiver providing a warm, soothing touch to the baby, which can help to lower the baby’s agitation level and promote relaxation. This technique is beneficial for calming colicky babies. Choices A, B, and C are incorrect because distraction with a red object, prone positioning, and tapping reflex techniques are not effective methods for managing colic in infants. Red object distraction is not a proven technique for soothing colicky babies. Prone positioning is not recommended for infants due to the risk of sudden infant death syndrome (SIDS). Tapping reflex techniques are not recognized as effective interventions for colic.
2. During data collection of a client with suspected carpal tunnel syndrome, a nurse plans to perform the Phalen test. The nurse should ask the client to perform which activity?
- A. Dorsiflex the foot
- B. Plantarflex the foot
- C. Hold the hands back to back while flexing the wrists 90 degrees for 60 seconds
- D. Hyperextend the fingers with the palmar surfaces of the hands touching, holding the position for 60 seconds
Correct answer: Hold the hands back to back while flexing the wrists 90 degrees for 60 seconds
Rationale: In the Phalen test, the nurse asks the client to hold the hands back to back while flexing the wrists 90 degrees. This position puts pressure on the median nerve, eliciting symptoms in carpal tunnel syndrome. Dorsiflexing or plantarflexing the foot and hyperextending the fingers are not associated with testing for carpal tunnel syndrome. Acute flexion of the wrist for 60 seconds produces no symptoms in the normal hand.
3. A client with a closed chest tube drainage system accidentally disconnects the chest tube while being turned by the nurse. What should the nurse do first?
- A. Submerge the end of the chest tube in a bottle of sterile water
- B. Clamp the chest tube with a Kelly clamp
- C. Call the health care provider
- D. Instruct the client to inhale and hold his breath
Correct answer: Submerge the end of the chest tube in a bottle of sterile water
Rationale: When a chest tube becomes disconnected, the priority action is to immediately reattach it to the drainage system or submerge the end in a bottle of sterile water or saline solution to reestablish a water seal. This helps prevent air from entering the pleural space and causing complications. Calling the health care provider is important but not the first action in this emergency. Instructing the client to inhale and hold his breath should be avoided as it can introduce atmospheric air into the pleural space, leading to potential issues. Clamping the chest tube is generally contraindicated, especially in cases of residual air leak or pneumothorax, as it may result in a tension pneumothorax by preventing air from escaping.
4. For which of the following conditions might blood be drawn to assess uric acid levels?
- A. asthma
- B. gout
- C. diverticulitis
- D. meningitis
Correct answer: gout
Rationale: Uric acid levels are commonly assessed in patients with gout. Gout is a type of arthritis caused by the buildup of uric acid crystals in the joints, leading to inflammation and pain. Monitoring uric acid levels helps in diagnosing and managing gout. Asthma, diverticulitis, and meningitis are not conditions where blood tests for uric acid levels are typically necessary. Asthma is a respiratory condition, diverticulitis involves inflammation of the digestive tract, and meningitis is an infection of the meninges in the brain and spinal cord.
5. A woman seeks assistance because she recently remembered childhood sexual abuse. The nurse should include which of the following goals for this client?
- A. prosecuting the perpetrator
- B. managing symptoms of anxiety and fear
- C. determining if the memories are real
- D. collaborating with the client’s story
Correct answer: managing symptoms of anxiety and fear
Rationale: The correct answer is 'managing symptoms of anxiety and fear.' When a client remembers childhood sexual abuse, the nurse's primary goal should be to help the client cope with the emotional distress and symptoms such as anxiety and fear. Prosecuting the perpetrator is not within the nurse's scope of practice and is a legal matter. Determining if the memories are real is not the nurse's role; the focus should be on providing support and care. Collaborating with the client's story is vague and does not address the immediate emotional needs of the client.
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