NCLEX NCLEX-PN
NCLEX PN Test Bank
1. Nail and foot care are essential in meeting the basic hygiene needs of clients. Important assessments by the nurse in this area include:
- A. a full-body assessment is not specific to nail and foot care.
- B. the essential lab work of the client is not related to nail and foot assessments.
- C. the nail beds and the tissue surrounding the nails.
- D. foot corns and calluses only neglect other important aspects of nail and foot care.
Correct answer: the nail beds and the tissue surrounding the nails.
Rationale: The correct answer is to assess the nail beds and the tissue surrounding the nails. This assessment is crucial to identify abnormal discoloration, lesions, paronychia, dryness, breaks in the skin, pressure areas, or any other unusual appearances. Choice A is incorrect as a full-body assessment is broader and not specific to nail and foot care. Choice B is incorrect as lab work is not directly related to nail and foot assessments. Choice D is incorrect as it focuses only on foot corns and calluses, neglecting other important aspects of nail and foot care.
2. Which symptoms is the client who overdosed on barbiturates most likely to exhibit?
- A. Bradypnea and bradycardia
- B. Hyperthermia and drowsiness
- C. Hyperreflexia and slurred speech
- D. Tachycardia and psychosis
Correct answer: Bradypnea and bradycardia
Rationale: The correct answer is bradypnea and bradycardia. Barbiturates are central nervous system (CNS) depressants, which will slow down the respiratory rate (bradypnea) and heart rate (bradycardia). Choice B, hyperthermia and drowsiness, is incorrect as barbiturate overdose typically does not cause hyperthermia but rather hypothermia. Hyperreflexia and slurred speech (Choice C) are more indicative of stimulant overdoses rather than CNS depressants like barbiturates. Tachycardia and psychosis (Choice D) are also not typically seen in barbiturate overdose, as these drugs tend to depress the CNS rather than cause symptoms of increased heart rate or psychosis.
3. A teenage client is admitted to the hospital because of acetaminophen (Tylenol) overdose. Overdoses of acetaminophen can precipitate life-threatening abnormalities in which of the following organs?
- A. lungs
- B. liver
- C. kidneys
- D. adrenal glands
Correct answer: liver
Rationale: Acetaminophen is extensively metabolized in the liver. An overdose of acetaminophen can lead to severe liver damage and even liver failure, which can be life-threatening. Choices A, C, and D are incorrect because although prolonged use of acetaminophen may lead to an increased risk of renal dysfunction, a single overdose does not typically cause life-threatening abnormalities in the lungs, kidneys, or adrenal glands.
4. Which of the following nursing diagnoses is most appropriate for a client with a new colostomy?
- A. Excess Fluid Volume
- B. Risk for Aspiration
- C. Disturbed Body Image
- D. Urinary Retention
Correct answer: Disturbed Body Image
Rationale: Disturbed Body Image is the most appropriate nursing diagnosis for a client with a new colostomy. A new colostomy can significantly impact a person's body image and self-esteem due to the physical changes it brings. This can lead to emotional distress, adjustment issues, and concerns about body image. Excess Fluid Volume, Risk for Aspiration, and Urinary Retention are not directly related to the psychosocial impact of a new colostomy and are therefore not as relevant in this context. While Excess Fluid Volume, Risk for Aspiration, and Urinary Retention are important nursing diagnoses, they are not the priority when considering the psychological and emotional effects of a new colostomy.
5. How often should the intravenous tubing on total parenteral nutrition solutions be changed?
- A. every 24 hours
- B. every 36 hours
- C. every 48 hours
- D. every 72 hours
Correct answer: every 24 hours
Rationale: The correct answer is to change the intravenous tubing on total parenteral nutrition solutions every 24 hours. This frequency is necessary due to the high risk of bacterial growth associated with TPN solutions. Changing the tubing every 24 hours helps prevent contamination and bloodstream infections. Choices B, C, and D are incorrect because waiting longer intervals increases the risk of introducing harmful bacteria into the patient's system, leading to potentially severe complications.
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