NCLEX NCLEX-PN
2024 PN NCLEX Questions
1. A paraplegic client is in the hospital to be treated for an electrolyte imbalance. Which level of care is the client currently receiving?
- A. primary prevention
- B. secondary prevention
- C. tertiary prevention
- D. health promotion
Correct answer: B
Rationale: The correct answer is B: secondary prevention. The client is currently receiving secondary prevention care. Secondary prevention focuses on early detection of disease, prompt intervention, and health maintenance for clients experiencing health problems. In this case, the electrolyte imbalance is a health problem that requires treatment to prevent further complications. Choices A, C, and D are incorrect because primary prevention is focused on health promotion and specific protections against illness before it occurs, tertiary prevention is aimed at helping rehabilitate clients after the illness is diagnosed and treated, and health promotion is a broader concept that includes activities aimed at improving overall health and well-being rather than targeting a specific health problem like an electrolyte imbalance.
2. During the examination of a client's throat, a nurse touches the posterior wall with a tongue blade and elicits the gag reflex. The nurse documents normal function of which cranial nerves?
- A. Cranial nerves V and VI
- B. Cranial nerves XII and VIII
- C. Cranial nerves XII and VIII
- D. Cranial nerves IX and X
Correct answer: Cranial nerves IX and X
Rationale: The correct answer is cranial nerves IX (glossopharyngeal nerve) and X (vagus nerve). When the nurse touches the posterior pharyngeal wall with a tongue blade and elicits the gag reflex, it indicates normal function of these nerves. Cranial nerves V (trigeminal nerve) and VI (abducens nerve) are not directly responsible for the gag reflex. Cranial nerves XII (hypoglossal nerve) and VIII (vestibulocochlear nerve) are not directly involved in eliciting the gag reflex. Testing cranial nerve I involves smell function, and cranial nerve II is related to eye examinations, making them irrelevant in this scenario.
3. The LPN is receiving the report on a comatose client at the start of the shift at 1500. What statement should be of most concern?
- A. The client was repositioned on his right side at 1100.
- B. The client was bathed, and the skin was assessed head-to-toe at 0900 with no abnormal findings.
- C. The client’s PEG tube was changed 6 months ago.
- D. The client’s indwelling urinary catheter was last changed 5 days ago.
Correct answer: The client’s indwelling urinary catheter was last changed 5 days ago.
Rationale: When caring for a comatose client, it is crucial to monitor and maintain the integrity of the indwelling urinary catheter to prevent urinary tract infections and other complications. Changing the urinary catheter less frequently than recommended increases the risk of infection. In this scenario, the most concerning issue is the prolonged duration since the last change of the indwelling urinary catheter, which poses an immediate risk to the client's health. While repositioning every 2 hours is essential to prevent skin breakdown, the most critical aspect in this case is the catheter care. Bathing and skin assessment are important for overall hygiene and skin integrity but are not as urgent as catheter care. The timing of the PEG tube change, while relevant for care planning, is not as immediate a concern as the indwelling urinary catheter status.
4. A Mexican American client with epilepsy is being seen at the clinic for an initial examination. The nurse understands which primary purpose of including cultural information in the health assessment?
- A. Confirm the medical diagnosis.
- B. Make accurate nursing diagnoses.
- C. Identify any hereditary traits related to the epilepsy.
- D. Determine what the client believes has caused the epilepsy.
Correct answer: Determine what the client believes has caused the epilepsy.
Rationale: The primary purpose for including cultural information in the health assessment is to determine what the client believes has caused the illness. In Mexican American culture, epilepsy is seen as a reflection of physical imbalance. While gathering data on hereditary traits and formulating nursing diagnoses are important, they are not the primary reasons for including cultural information in the health assessment. It is crucial to understand the client's beliefs as they may impact their perceptions of health, treatment adherence, and overall care. It is not the nurse's role to confirm a medical diagnosis, as this is the responsibility of the healthcare provider.
5. Which of the following is an inappropriate item to include in planning care for a severely neutropenic client?
- A. Transfuse neutrophils (granulocytes) to prevent infection.
- B. Exclude raw vegetables from the diet.
- C. Avoid administering rectal suppositories.
- D. Prohibit vases of fresh flowers and plants in the client’s room.
Correct answer: Transfuse neutrophils (granulocytes) to prevent infection.
Rationale: Transfusing neutrophils (granulocytes) to prevent infection is inappropriate in the care of a severely neutropenic client. Neutrophils normally comprise 70% of all white blood cells and can be beneficial in a selected population of infected, severely granulocytopenic clients (less than 500/mm3) who do not respond to antibiotic therapy and who are expected to experience prolonged suppression of granulocyte production. Therefore, transfusing neutrophils is not a standard practice in caring for neutropenic clients. The other choices are appropriate in caring for a severely neutropenic client: excluding raw vegetables from the diet to reduce the risk of infections from potential pathogens, avoiding administering rectal suppositories to prevent any injury or infection due to mucosal damage, and prohibiting vases of fresh flowers and plants in the client’s room to minimize the risk of exposure to environmental pathogens.
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