NCLEX NCLEX-PN
Quizlet NCLEX PN 2023
1. Metformin (Glucophage) is administered to clients with type II diabetes mellitus. Metformin is an example of:
- A. an antihyperglycemic agent.
- B. a hypoglycemic agent.
- C. an insulin analogue.
- D. a pancreatic alpha cell stimulant
Correct answer: an antihyperglycemic agent.
Rationale: Metformin is classified as an antihyperglycemic agent because it works by reducing hepatic glucose output and decreasing glucose absorption from the gut, thereby preventing hyperglycemia. Choice B, a hypoglycemic agent, is incorrect as hypoglycemic agents stimulate insulin production, which is not the mechanism of action of metformin. Choice C, an insulin analogue, is incorrect as metformin is not a type of insulin but a distinct medication. Choice D, a pancreatic alpha cell stimulant, is incorrect as metformin does not stimulate any pancreatic cells, but rather acts on the liver and gut to lower blood sugar levels.
2. When observing a dressing change by a graduate nurse on a Stage III pressure ulcer to the greater trochanter by the staff nurse, a need for further teaching is indicated after the following observation by the nurse:
- A. The new graduate nurse irrigates the pressure ulcer with 50cc of NS.
- B. The new graduate irrigates the pressure ulcer with half-strength hydrogen peroxide.
- C. The new graduate packs the wound with sterile kerlix soaked in NS.
- D. The new graduate applies a Duoderm dressing over the wound after cleansing.
Correct answer: The new graduate irrigates the pressure ulcer with half-strength hydrogen peroxide.
Rationale: The correct answer is that the new graduate irrigates the pressure ulcer with half-strength hydrogen peroxide. Pressure ulcers should not be cleaned with substances that are cytotoxic, such as hydrogen peroxide or betadine. This can cause further damage to the wound and delay the healing process. Choice A is incorrect because irrigating the pressure ulcer with normal saline is an appropriate practice. Choice C is incorrect because packing the wound with sterile kerlix soaked in normal saline is also an appropriate step. Choice D is incorrect because applying a Duoderm dressing after cleansing is a standard procedure in wound care.
3. A client has just returned from surgery where a femoral-popliteal bypass was performed. The nurse has assessed the client and is unable to feel a pulse at either the dorsalis pedis or the posterior tibial sites of the left foot. The foot feels warm, and the color is pink. What action should the nurse perform next to prevent ischemia?
- A. Notify the physician immediately
- B. Obtain a Doppler device to check for pulses, and notify the physician if they are still absent
- C. Wait 30 minutes and recheck the pulses
- D. Document the finding
Correct answer: Obtain a Doppler device to check for pulses, and notify the physician if they are still absent
Rationale: The nurse should immediately obtain a Doppler device and recheck the pulses. The dorsalis pedis and posterior tibial pulses can be difficult to assess and might need to be verified with a Doppler device. Since the client just had surgery with a risk of arterial insufficiency, close monitoring is crucial. If pulses are not palpable, it indicates an emergent situation requiring immediate physician notification. Waiting 30 minutes before reassessment could lead to foot ischemia. While documenting findings is essential, it should follow pulse confirmation or necessary interventions to ensure the client's foot viability.
4. Which action by the nurse represents the ethical principle of benevolence?
- A. The nurse administers an immunization to a child even though it may cause discomfort
- B. The nurse follows a plan of care designed to relieve pain in a client with cancer
- C. The nurse provides equal amounts of care to all assigned clients on the basis of illness acuity
- D. The nurse upholds a client’s decision to refuse chemotherapy for lung cancer
Correct answer: The nurse administers an immunization to a child even though it may cause discomfort
Rationale: Benevolence is taking action to help others. In this scenario, administering an immunization to a child, even though it may cause discomfort, aligns with the principle of benevolence as the benefits of protection from disease outweigh the temporary discomfort. Fidelity refers to keeping promises made to clients, families, and other healthcare professionals. Autonomy is a person’s independence, and respecting autonomy means agreeing to respect an individual’s right to determine their course of action. Justice refers to fairness and equity, including the fair allocation of resources, such as nursing care for all clients. Choice B is incorrect as it pertains more to the ethical principle of beneficence rather than benevolence, which focuses on doing good for others without an expectation of something in return. Choices C and D are incorrect as they do not directly align with the principle of benevolence.
5. The nursing assistant hitting the client in the long-term care facility can be charged with:
- A. Negligence
- B. Tort
- C. Assault
- D. Malpractice
Correct answer: Assault
Rationale: Assault is the appropriate charge in this scenario. Assault involves physically striking or touching someone inappropriately. Negligence (Choice A) refers to failing to provide proper care for the client. Tort (Choice B) is a wrongful act committed against the client or their property. Malpractice (Choice D) is the failure to perform an act that should have been done or the improper performance of an act resulting in harm to the client. Since the nursing assistant physically struck the client, the charge of assault is most fitting.
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