NCLEX-PN
Quizlet NCLEX PN 2023
1. A nurse is instructing a patient on the order of sensations with the application of an ice water bath for a swollen right ankle. Which of the following is the correct order of sensations experienced with an ice water bath?
- A. cold, burning, aching, and numbness
- B. burning, aching, cold, and numbness
- C. aching, cold, burning, and numbness
- D. cold, aching, burning, and numbness
Correct answer: A
Rationale: The correct order of sensations experienced with an ice water bath is cold, burning, aching, and numbness, as stated by the acronym CBAN (cold, burn, ache, numbness). Option A is the correct sequence. Choice B is incorrect as it starts with burning, which typically follows the cold sensation. Choice C is incorrect as aching is usually felt after the burning sensation. Choice D is incorrect as aching usually occurs after the burning sensation.
2. A healthcare professional is reviewing a patient's arterial blood gas values. Which of the following conditions apply under the following values? pH- 7.49 Bicarbonate ion 24 mEq/dl PaCO2 - 31 mmHg PaO2 - 52 mmHg FiO2 - 0.22
- A. respiratory acidosis
- B. respiratory alkalosis
- C. metabolic acidosis
- D. metabolic alkalosis
Correct answer: B
Rationale: The given blood gas values indicate respiratory alkalosis. A high pH and low PaCO2 level are consistent with respiratory alkalosis. In this scenario, no compensation for the alkalosis is noted, ruling out metabolic acidosis or alkalosis. Metabolic conditions would usually involve changes in bicarbonate levels, which remain within the normal range in this case.
3. A client is admitted to the floor with vomiting and diarrhea for three days. She is receiving IV fluids at 200cc/hr via pump. A priority action for the nurse would be:
- A. Obtaining Intake and Output.
- B. Frequent lung assessments.
- C. Vital signs every shift.
- D. Monitoring the IV site for infiltration.
Correct answer: D
Rationale: In this scenario, the correct priority action for the nurse would be monitoring the IV site for infiltration. The client is receiving IV fluids at a rapid rate, making it crucial to ensure that the IV site is intact and not causing any complications like infiltration, which can lead to tissue damage. While frequent lung assessments are important for detecting signs of fluid overload, in this case, ensuring the IV site's integrity takes precedence. Obtaining Intake and Output is relevant but not the priority over monitoring the IV site. Vital signs are essential, but given the situation, the immediate concern is the IV site's condition to prevent complications.
4. In the Emergency Department (ED), which client should the nurse see first?
- A. COPD client with a non-productive cough
- B. Diabetic client who has an infected sore on the foot
- C. Client with adrenal insufficiency who feels weak
- D. Client with a fracture of the forearm in an air splint
Correct answer: C
Rationale: In the Emergency Department, the priority is to assess and manage clients based on the urgency of their conditions. A client with adrenal insufficiency presenting with weakness should be seen first as this could indicate a state of shock, which requires immediate attention to stabilize the client's condition. Weakness in adrenal insufficiency can progress rapidly to a life-threatening adrenal crisis. Choice A, a COPD client with a non-productive cough, may need treatment but is not immediately life-threatening. Choice B, a diabetic client with an infected sore on the foot, requires timely care to prevent complications but can generally wait for evaluation compared to the potential urgency of adrenal insufficiency. Choice D, a client with a fracture of the forearm in an air splint, is important but not as time-sensitive as a client potentially in shock.
5. Which of the following injuries, presented by a client entering the Emergency Department, is the highest priority?
- A. open leg fracture
- B. open head injury
- C. stab wound to the chest
- D. traumatic amputation of a thumb
Correct answer: C
Rationale: A stab wound to the chest is the highest priority injury. This type of injury can lead to lung collapse and mediastinal shift, potentially resulting in death if left untreated. Treating an obstructed airway or a chest wound takes precedence over addressing hemorrhage. The principle of ABC (airway, breathing, and circulation) guides care decisions in prioritizing life-threatening situations. An open leg fracture, open head injury, and traumatic amputation of a thumb, while serious, do not pose an immediate threat to life compared to a stab wound to the chest. An open leg fracture may lead to significant blood loss but is not immediately life-threatening. An open head injury requires assessment and intervention but does not impact airway, breathing, or circulation directly. Traumatic amputation of a thumb is a serious injury but can be managed after addressing more life-threatening conditions.
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