a nurse is working in an outpatient orthopedic clinic during the patients history the patient reports i tore 3 of my 4 rotator cuff muscles in the pas
Logo

Nursing Elites

NCLEX-PN

2024 PN NCLEX Questions

1. A patient reports, "I tore 3 of my 4 Rotator cuff muscles in the past."? Which of the following muscles cannot be considered as possibly being torn?

Correct answer: B

Rationale: The correct answer is Teres major. The Rotator Cuff consists of Teres Minor, Infraspinatus, Supraspinatus, and Subscapularis muscles, not Teres major. Teres major is not part of the rotator cuff, so it cannot be considered as possibly being torn. The other choices, Teres minor, Supraspinatus, and Infraspinatus, are all part of the Rotator Cuff and could potentially be torn in this patient's case.

2. The nurse is caring for a postpartum woman who has relinquished her baby for adoption. The care plan for the client should include which of the following priority strategies?

Correct answer: C

Rationale: When caring for a postpartum woman who has relinquished her baby for adoption, it is crucial for the nurse to provide opportunities for the woman to express her feelings. Most women who make this decision have done so with love and pain, and it is essential to allow them to verbalize their emotions, which may include grief, loneliness, and guilt. Referring the woman for grief counseling may be necessary if she lacks a support system or requests help to navigate her grief. Allowing the woman to see her baby is important, and the nurse should respect her wishes regarding visitation as it can aid in the grief process. While the woman does have the right to change her mind about relinquishment until final legal arrangements are made, suggesting this option may inadvertently influence her decision and should be approached cautiously. Therefore, providing emotional support and opportunities for expression are the priority strategies in this situation.

3. A client with Kawasaki disease has bilateral congestion of the conjunctivae, dry cracked lips, a strawberry tongue, and edema of the hands and feet followed by desquamation of fingers and toes. Which of the following nursing measures is most appropriate to meet the expected outcome of positive body image?

Correct answer: C

Rationale: Educating the client and their family about the progression of Kawasaki disease is crucial for promoting a positive body image. By explaining when symptoms are expected to improve and resolve, the client and family can better understand that there will be no permanent disruption in physical appearance that could negatively impact body image. Administering immune globulin intravenously is a treatment for Kawasaki disease but does not directly address body image concerns. Assessing the extremities for edema, redness, and desquamation every 8 hours is important for monitoring the disease but does not directly address body image concerns. Assessing heart sounds and rhythm is essential for evaluating cardiac effects of Kawasaki disease but is not the most direct measure for promoting a positive body image.

4. How often should the nurse change the intravenous tubing on total parenteral nutrition solutions?

Correct answer: A

Rationale: The correct answer is 'every 24 hours.' Changing the intravenous tubing on total parenteral nutrition solutions every 24 hours is crucial due to the high risk of bacterial growth. Bacterial contamination can lead to serious infections in patients receiving total parenteral nutrition. Choices B, C, and D are incorrect because waiting longer intervals between tubing changes increases the risk of bacterial contamination and infection, compromising patient safety. It is essential to maintain a strict 24-hour schedule to minimize the risk of complications associated with bacterial contamination.

5. The nurse is assessing an 18-month-old. Which of these statements made by the parent or caregiver would require follow-up?

Correct answer: B

Rationale: The correct answer is 'My child has recently taken a few steps but does not seem stable when standing.' By 18 months of age, children should have taken their first steps and stand well. If a child hasn't made progress by this age, a physical therapy evaluation may be necessary. It is normal for an 18-month-old to start using a spoon to eat. However, the use of two-word phrases is not typically expected until 2 years of age. Separation anxiety is a common developmental phase that typically occurs between 6 and 18 months, so it does not require immediate follow-up. Therefore, the statement about the child not being stable when standing raises a red flag and necessitates further evaluation.

Similar Questions

A nurse is assisting with data collection on the language development of a 9-month-old infant. Which developmental milestone does the nurse expect to note in an infant of this age?
The client is assessing a client who has recently found out she is pregnant. Which of the following statements would be a priority for the nurse to follow up on?
Intramuscular (IM) phytonadione (vitamin K) 0.5 mg is prescribed for a newborn. After the medication is prepared, in which anatomic site does the nurse administer it?
A school nurse provides information to the parents of school-age children regarding appropriate dental care. The nurse tells the parents that their children should perform which action?
A mother brings her 1-year-old child to the clinic. The child has no record of previous immunizations, and the mother confirms the child has not been immunized. Teaching by the nurse should include which of the following?

Access More Features

NCLEX PN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access

NCLEX PN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access

Other Courses