a nurse palpates a clients radial pulse noting the rate rhythm and force and concludes that the clients pulse is normal which notation would the nurse
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Nursing Elites

NCLEX-PN

Health Promotion and Maintenance NCLEX PN Questions

1. A nurse palpates a client’s radial pulse, noting the rate, rhythm, and force, and concludes that the client’s pulse is normal. Which notation would the nurse make in the client’s record to document the force of the client’s pulse?

Correct answer: C

Rationale: When assessing a pulse, the nurse should note the rhythm, amplitude, and symmetry of pulses and should compare peripheral pulses on the two sides for rate, rhythm, and quality. A 4-point scale may be used to assess the force (amplitude) of the pulse: 4+ for a bounding pulse, 3+ for an increased pulse, 2+ for a normal pulse, and 1+ for a weak pulse. In this case, the nurse would grade the client’s pulse as 2+ based on the description of a normal pulse. Therefore, the correct notation for the force of the client’s pulse is '2+' as it indicates a normal pulse. Choices A, B, and D are incorrect as they represent different levels of pulse force that do not align with the description given in the scenario.

2. During a report from an ER nurse about a client, the nurse identifies a statement that requires additional follow-up. Which of the following statements needs further clarification?

Correct answer: A

Rationale: The correct answer requires further follow-up as the nurse needs to know the duration and dosage of aspirin since it can impact the patient's bleeding risk. Choice B does not require immediate follow-up as not taking antacids for three days is not critical. Choice C indicates a necessary decision made by the client to stop ibuprofen after developing gastric ulcers, hence no immediate follow-up is needed. Choice D provides important information, but the priority is to address the lack of specificity regarding the client's aspirin use, which is crucial for assessing bleeding risk and potential interactions.

3. A nurse is assisting with data collection on an older client who will be seen by a physician in a health care clinic. When the nurse asks the client about sexual and reproductive function, the client reports concern about sexual dysfunction. What should be the nurse's next action?

Correct answer: D

Rationale: Sexual dysfunction is not a normal process of aging. The prevalence of chronic illness and medication use is higher among older adults than in the younger population. Illnesses and medications can interfere with the normal sexual function of older men and women. It is crucial to assess the medications the client is taking as they could be contributing to the reported sexual dysfunction. While documenting the concern and informing the healthcare provider are important steps, the immediate priority is to gather information on the medications that could be impacting the client's sexual function. Therefore, the nurse's next action should be to ask the client about the medications he is taking.

4. What effect can medication bound to protein have?

Correct answer: C

Rationale: Medication bound to protein leads to less availability to produce desired medicinal effects because only unbound drugs can interact with active receptor sites. If a drug is bound to protein, it cannot bind with a receptor site, reducing its effectiveness. Choice A is incorrect because binding to protein reduces drug availability. Choice B is incorrect because distribution to receptor sites is ineffective if the drug is bound to protein. Choice D is incorrect because metabolism does not occur until the drug is removed from the protein molecule by the liver, allowing the protein to return to circulation.

5. 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.

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