NCLEX NCLEX-PN
NCLEX PN 2023 Quizlet
1. Nursing care for a client undergoing chemotherapy includes assessment for signs of bone marrow depression. Which finding accounts for some of the symptoms related to bone marrow depression?
- A. erythrocytosis
- B. leukocytosis
- C. polycythemia
- D. thrombocytopenia
Correct answer: thrombocytopenia
Rationale: Thrombocytopenia is an abnormal decrease in the number of platelets, which results in bleeding tendencies. During chemotherapy, bone marrow depression can lead to a reduction in platelet production, causing thrombocytopenia. Erythrocytosis is an abnormal increase in red blood cells, leukocytosis is an increase in white blood cells, and polycythemia is an excess of red blood cells, which is synonymous with erythrocytosis. In the context of chemotherapy, the focus is on the decrease in red and white blood cells, making thrombocytopenia the most relevant finding.
2. While working the 11 p.m. to 7 a.m. shift at the long-term care unit, the nurse gathers the nursing staff to listen to the 3 to 11 p.m. intershift report. The nurse notes that a staff member has an odor of alcohol on her breath, slurred speech, and an unsteady gait, suspecting alcohol intoxication. What is the most appropriate action for the nurse to take?
- A. Contact the nursing supervisor.
- B. Tell the staff member that she is not allowed to administer medications.
- C. Ask the staff member how much alcohol she has consumed.
- D. Ask the staff member to rest in the nurses' lounge until the effects of the alcohol wear off.
Correct answer: Contact the nursing supervisor.
Rationale: When a staff member reports to work showing signs of alcohol intoxication, the nurse should objectively note the symptoms and ask a second person to confirm these observations. It is crucial to contact the nursing supervisor immediately. An odor of alcohol, slurred speech, unsteady gait, and errors in judgment are indicators of intoxication, posing a risk to client safety. The staff member should be removed from the client care area. Detailed documentation of the incident is essential, including observations, actions taken, future plans, and the staff member's signature and date on the recorded incident memo. If the staff member refuses to sign, this should be noted by the nurse and a witness. Asking the staff member to rest in the nurses' lounge or restricting medication administration does not ensure client safety, as the staff member could still jeopardize it. Inquiring about the amount of alcohol consumed is confrontational and not relevant to the immediate need of ensuring safety.
3. After a left heart catheterization (LHC), a client complains of severe foot pain on the side of the femoral stick. The nurse notes pulselessness, pallor, and a cold extremity. What should the nurse’s next action be?
- A. Administer an anticoagulant.
- B. Warm the room and re-assess.
- C. Increase IV fluids.
- D. Notify the physician stat.
Correct answer: Notify the physician stat
Rationale: The correct action for the nurse to take next is to notify the physician immediately (stat). The client's symptoms of foot pain, pulselessness, pallor, and cold extremity suggest a potential vascular complication, such as arterial occlusion. Prompt notification of the physician is crucial as this condition requires urgent intervention to restore blood flow and prevent tissue damage. Administering an anticoagulant (Choice A) without physician evaluation could be harmful as the underlying cause needs to be determined first. Warming the room and re-assessing (Choice B) may delay necessary treatment. Increasing IV fluids (Choice C) is unlikely to address the urgent vascular issue indicated by the symptoms described.
4. A middle-aged woman tells the nurse that she has been experiencing irregular menses for the past six months. The nurse should assess the woman for other symptoms of:
- A. climacteric
- B. menopause
- C. perimenopause
- D. postmenopause
Correct answer: perimenopause
Rationale: Perimenopause refers to a period in which hormonal changes occur gradually, ovarian function diminishes, and menses become irregular. It typically lasts around five years. In the case of the middle-aged woman experiencing irregular menses for six months, she aligns with perimenopause as it involves irregular menstrual cycles, one of the common symptoms during this transitional phase. Climacteric is a term describing the period of life with physiologic changes leading to the end of a woman's reproductive ability but not specifically characterized by irregular menses. Menopause marks the permanent cessation of menses and does not involve the transitional irregularities seen in perimenopause. Postmenopause is the phase after the completion of menopausal changes.
5. A school nurse provides information to the parents of school-age children regarding appropriate dental care. The nurse tells the parents that their children should perform which action?
- A. Brush and floss their teeth after meals and at bedtime
- B. Brush their teeth every morning and at bedtime and floss the teeth once a day, preferably at bedtime
- C. Brush their teeth every morning and at bedtime
- D. Brush and floss their teeth every morning and at bedtime
Correct answer: Brush and floss their teeth after meals and at bedtime
Rationale: School-age children are capable of taking responsibility for their own dental hygiene. Establishing good oral health habits during childhood can lead to a lifetime of cavity prevention. The nurse advises the parents that their children should brush with fluoride toothpaste and floss between their teeth after meals and before bedtime. This routine helps maintain good oral health and teaches children the importance of dental care. Choice A is the correct answer as it emphasizes both brushing and flossing after meals and at bedtime, which are crucial for effective dental care. Choices B, C, and D are incorrect as they do not stress the significance of both brushing and flossing after meals, which is essential for proper oral hygiene.
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