NCLEX-PN
2024 Nclex Questions
1. An elderly client is diagnosed with ovarian cancer. She has surgery followed by chemotherapy with fluorouracil (Adrucil) IV. What should the nurse do if she notices crystals and cloudiness in the IV medication?
- A. Discard the solution and order a new bag
- B. Warm the solution
- C. Continue the infusion and document the finding
- D. Discontinue the medication
Correct answer: A
Rationale: Crystals in the solution are not normal and should not be administered to the client. Discarding the solution and ordering a new bag is the correct action to ensure the client's safety. Warming the solution, as suggested in answer B, will not resolve the issue of crystals and cloudiness, which could potentially harm the client. Continuing the infusion, as in answer C, could pose a risk to the client due to the presence of abnormal substances. Answer D, discontinuing the medication, would typically require a doctor's order and should be done after discarding the contaminated solution.
2. The licensed practical nurse assigned to the postpartum unit is preparing to administer Rhogam to a postpartum client. Which woman is not a candidate for RhoGam?
- A. A gravida IV para 3 that is Rh negative with an Rh-positive baby
- B. A gravida I para 1 that is Rh negative with an Rh-positive baby
- C. A gravida II para 0 that is Rh negative admitted after a stillbirth delivery
- D. A gravida IV para 2 that is Rh negative with an Rh-negative baby
Correct answer: D
Rationale: The mothers in answers A, B, and C all require RhoGam as they are Rh negative with an Rh-positive baby or have experienced a stillbirth delivery, making them candidates for RhoGam injection. The mother in answer D is the only one who does not require Rhogam because she is Rh negative with an Rh-negative baby, eliminating the need for RhoGam administration.
3. After group therapy, the female victim of intimate partner violence confides to the nurse that she does not feel in any immediate danger. Which of the following statements about victims of domestic violence is true?
- A. Victims of domestic violence are often the best predictors of their risk of harm.
- B. Victims of domestic violence often overestimate their safety risk.
- C. Victims of domestic violence are typically in a state of denial.
- D. Victims of domestic violence know that keeping peace with their partner is the best method of preventing another attack.
Correct answer: A
Rationale: Victims of domestic violence are often correct at predicting their risk of harm. It is crucial for the nurse to ensure that the client is expressing herself authentically and not downplaying any potential danger. While victims can be insightful about their risk, it's essential to involve proper authorities, such as the police, in situations of intimate partner violence to ensure safety and provide necessary support. Choice B is incorrect because victims may not necessarily overestimate their safety risk. Choice C is incorrect as not all victims are in a state of denial; some may recognize the dangers they face. Choice D is incorrect because victims may not believe that keeping peace with their partner is the best way to prevent future attacks, as each individual's situation and mindset vary.
4. What are the three major sequential maturational crises for females?
- A. puberty, pregnancy, and menopause.
- B. death of a spouse, menopause, and childbirth.
- C. rape, divorce, and menarche.
- D. dating, engagement, and separation.
Correct answer: A
Rationale: The three major sequential maturational crises affecting females are puberty, pregnancy, and menopause. Puberty signifies the beginning of menarche, the first menstrual period. Pregnancy is a transformative experience with long-lasting effects on a woman's life. Menopause marks the end of menstrual cycles. These milestones are well-documented in research and are significant events in a woman's life. Nurses play a vital role in supporting females through these stages. Choices B, C, and D are incorrect as they do not accurately represent the recognized sequential maturational crises in a female's life.
5. A client asks the nurse if all donor blood products are cross-matched with the recipient to prevent a transfusion reaction. Which of the following always requires cross-matching?
- A. packed red blood cells
- B. platelets
- C. plasma
- D. granulocytes
Correct answer: A
Rationale: Corrected Rationale: Packed red blood cells contain antigens and antibodies that must be matched between the donor and recipient to prevent transfusion reactions. Platelets, plasma, and granulocytes do not contain red blood cells, so they do not require cross-matching. Platelets are matched based on ABO compatibility, while plasma and granulocytes are not routinely cross-matched as they lack red cell antigens.
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