NCLEX-PN
Nclex Exam Cram Practice Questions
1. Acyclovir (Zovirax) is the agent of choice for which of the following infections?
- A. HIV
- B. AIDS
- C. candida
- D. herpes
Correct answer: D
Rationale: Acyclovir is an antiviral medication specifically effective in treating herpes infections. It works by inhibiting the replication of the herpes virus, shortening the duration of the infection. While Acyclovir can be used in HIV and AIDS patients to treat opportunistic viral infections, it is not a primary drug for managing HIV or AIDS itself. Candida is a type of fungus, and infections caused by Candida are treated with antifungal medications, not antivirals like Acyclovir. Therefore, the correct answer is herpes.
2. When a physician removes a chest tube, which type of dressing is recommended to be placed over the site?
- A. transparent dressing
- B. colloidal dressing
- C. petrolatum gauze
- D. nonadherent dressing
Correct answer: C
Rationale: Petrolatum gauze is recommended to be placed over the site when a physician removes a chest tube because it forms an airtight seal, helping prevent air from entering the pleural space. This airtight seal is crucial to avoid complications such as a pneumothorax. Transparent dressing is not ideal for this purpose as it may not provide a sufficient seal due to its design. Colloidal dressing and nonadherent dressing are also not suitable for chest tube removal sites as they do not offer the same level of protection against air leakage and may not provide the necessary sealing properties.
3. A nurse monitoring a client with a chest tube notes that there is no tidaling of fluid in the water seal chamber. After further assessment, the nurse suspects that the client's lung has reexpanded and notifies the healthcare provider. The healthcare provider verifies with the use of a chest x-ray that the lung has reexpanded, then calls the nurse to ask that the chest tube be removed. Which action should the nurse take first?
- A. Explain the procedure to the client, then remove the chest tube.
- B. Call the nursing supervisor.
- C. Inform the healthcare provider that removal of a chest tube is not a nursing procedure.
- D. Obtain petrolatum-impregnated gauze and ask another nurse to assist in removing the chest tube.
Correct answer: C
Rationale: The correct action for the nurse to take first is to inform the healthcare provider that removal of a chest tube is not a nursing procedure. Actual removal of a chest tube is the duty of a healthcare provider. If the healthcare provider insists that the nurse remove the tube, the nurse must contact the nursing supervisor. Some agencies' policies and procedures may permit an advanced practice nurse to remove a chest tube, but there is no information in the question to indicate that the nurse is an advanced practice nurse. Choice A is incorrect because the nurse should not proceed with removing the chest tube without proper authorization. Choice B is incorrect as calling the nursing supervisor should come after clarifying with the healthcare provider. Choice D is incorrect as the nurse should not begin the process of removing the chest tube without proper guidance and authorization.
4. Which of the following statements by a client indicates adequate preparation for magnetic resonance imaging?
- A. "I should wear earplugs during the test."?
- B. "I should remove my metal jewelry before the test."?
- C. "I should inform the healthcare provider about my pacemaker."?
- D. "I should inform the healthcare provider about my artificial hip."?
Correct answer: A
Rationale: The correct statement is, '"I should wear earplugs during the test,"?' as MRI scanners produce loud noises requiring ear protection. Metal objects, including jewelry, are not allowed inside the MRI room due to safety concerns related to the magnetic field. Choices B, C, and D are incorrect. Choice B is wrong because metal objects, including jewelry, are not permitted in the MRI room. Choices C and D are incorrect as having a pacemaker or an artificial hip raises concerns due to the magnetic field in MRI, requiring special precautions or considerations. It is crucial for individuals with such implants to inform their healthcare provider to assess the risks and determine the appropriate course of action.
5. The nurse assesses a client for physiological risk factors for falls. The nurse should conclude that the client is not at risk if which of the following is discovered?
- A. history of dizziness
- B. need for a wheelchair due to reduced mobility
- C. weakness and fatigue noted when climbing stairs
- D. intact recent and remote memory
Correct answer: D
Rationale: The correct answer is intact recent and remote memory. Intact memory function indicates that the client is less likely to be at risk for falls as it suggests cognitive awareness and orientation, which are important for safety. Choices A, B, and C are risk factors for falls: a history of dizziness can lead to imbalance, the need for a wheelchair due to reduced mobility can increase fall risk, and weakness and fatigue when climbing stairs indicate physical limitations that predispose a client to falls. Therefore, these options would suggest an increased risk for falls.
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