NCLEX NCLEX-PN
PN Nclex Questions 2024
1. 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.
2. The client with a myocardial infarction comes to the nurse’s station stating that he is ready to go home because there is nothing wrong with him. Which defense mechanism is the client using?
- A. Rationalization
- B. Denial
- C. Projection
- D. Conversion reaction
Correct answer: Denial
Rationale: The correct answer is B: Denial. The client displaying denial refuses to acknowledge the reality of having a myocardial infarction. Rationalization (choice A) involves making excuses for behavior, not denying a condition. Projection (choice C) is attributing one's thoughts or feelings to others, not denying an illness. Conversion reaction (choice D) is converting psychological distress into physical symptoms, which is not evident in this scenario. Therefore, denial is the defense mechanism being used in this situation.
3. A client comes to the clinic for assessment of his physical status and guidelines for starting a weight-reduction diet. The client’s weight is 216 pounds and his height is 66 inches. The nurse identifies the BMI (body mass index) as:
- A. within normal limits, so a weight-reduction diet is unnecessary
- B. lower than normal, so education about nutrient-dense foods is needed
- C. indicating obesity because the BMI is 35
- D. indicating overweight status because the BMI is 27
Correct answer: indicating obesity because the BMI is 35
Rationale: Obesity is defined by a BMI of 30 or more with no co-morbid conditions. It is calculated by utilizing a chart or nomogram that plots height and weight. This client’s BMI is 35, indicating obesity. Choices A, B, and D are incorrect because the client's BMI is above 30, which falls under the obesity category. Therefore, a weight-reduction diet and increased physical activity are necessary to address the client's weight status and promote overall health.
4. Which of the following solutions is routinely used to flush an IV device before and after the administration of blood to a client?
- A. 0.9% sodium chloride
- B. 5% dextrose in water solution
- C. Sterile water
- D. Heparin sodium
Correct answer: 0.9% sodium chloride
Rationale: The correct answer is 0.9% sodium chloride. Normal saline is 0.9% sodium chloride, which has the same osmolarity as blood and does not cause cell lysis. Choices 2 and 3, 5% dextrose in water solution and sterile water, are hypotonic solutions that can lead to cell lysis. Choice 4, Heparin sodium, is an anticoagulant and is not routinely used to flush an IV device before and after the administration of blood.
5. A health care provider informs a nurse that the husband of an unconscious client with terminal cancer will not grant permission for a do-not-resuscitate (DNR) order. The health care provider tells the nurse to perform a 'slow code' and let the client 'rest in peace' if she stops breathing. How should the nurse respond?
- A. Telling the health care provider that the client would probably want to die in peace
- B. Telling the health care provider that if the client stops breathing, the health care provider will be called before any other actions are taken
- C. Telling the health care provider that all of the nurses on the unit agree with this plan
- D. Telling the health care provider that 'slow codes' are not acceptable
Correct answer: Telling the health care provider that 'slow codes' are not acceptable
Rationale: The nurse may not violate a family’s request regarding the client’s treatment plan. A 'slow code' is not acceptable, and the nurse should state this to the health care provider. The definition of a 'slow code' varies among health care facilities and personnel and could be interpreted as not performing resuscitative procedures as quickly as a competent person would. Resuscitative procedures that are performed more slowly than recommended by the American Heart Association are below the standard of care and could therefore serve as the basis for a lawsuit. The other options are inappropriate: Option A is speculative and does not address the issue directly; Option B does not challenge the unethical practice of a 'slow code'; Option C is irrelevant and does not address the ethical concerns raised by the health care provider's request.
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