NCLEX-PN
NCLEX PN Exam Cram
1. Ten-year-old Jackie is admitted to the hospital with a medical diagnosis of Rheumatic Fever. She relates a history of 'a sore throat about a month ago.' Bed rest with bathroom privileges is prescribed. Which of the following nursing assessments should be given the highest priority when assessing Jackie's condition?
- A. her response to hospitalization
- B. the presence of a macular rash on her trunk
- C. her cardiac status
- D. the presence of polyarthritis and joint pain
Correct answer: C
Rationale: Monitoring Jackie's cardiac status is of the highest priority in a patient with rheumatic fever. Rheumatic fever can lead to permanent cardiac damage, making it crucial to closely monitor the heart. Assessing for signs of carditis, such as murmurs or other cardiac symptoms, is essential. The second priority is evaluating joint symptoms for the presence of polyarthritis and pain, which are common manifestations of rheumatic fever. While assessing Jackie's response to hospitalization is important for her emotional well-being, it is not the highest priority. The presence of a macular rash, although relevant, is not as high a priority as monitoring cardiac status or assessing joint symptoms.
2. A patient has recently been prescribed Norvasc. Which of the following side effects should the patient specifically watch out for?
- A. Hypotension and Angina
- B. Hypertension
- C. Lower extremity edema
- D. Peripheral sensory loss and SOB
Correct answer: A
Rationale: The correct answer is 'Hypotension and Angina.' Norvasc is a medication known to cause hypotension (low blood pressure) and angina (chest pain) as side effects. These side effects are important for the patient to watch out for as they can indicate potential issues related to the medication. Choice B ('Hypertension') is incorrect as Norvasc is actually used to treat hypertension, not cause it. Choice C ('Lower extremity edema') is not a common side effect of Norvasc. Choice D ('Peripheral sensory loss and SOB') is not typically associated with Norvasc's side effects.
3. The nurse should plan to evaluate the earliest onset of effectiveness of nitroglycerin (Nitrostat) sublingual (SL) within what time frame?
- A. 15 seconds
- B. 3 minutes
- C. 5 minutes
- D. 15 minutes
Correct answer: B
Rationale: The onset of action for Nitrostat SL is 1 to 3 minutes. Therefore, the nurse should plan to evaluate the earliest onset of effectiveness within 3 minutes after administering the medication. Option A, 15 seconds, is too short of a time frame for the onset of action of Nitrostat. Option C, 5 minutes, is slightly delayed compared to the typical onset time. Option D, 15 minutes, is too long to wait for evaluating the effectiveness of Nitrostat sublingual administration.
4. Signs of impaired breathing in infants and children include all of the following except:
- A. nasal flaring
- B. grunting
- C. seesaw breathing
- D. quivering lips
Correct answer: D
Rationale: Signs of impaired breathing in infants and children typically include nasal flaring, grunting, and seesaw breathing. Nasal flaring is the widening of the nostrils during breathing to help with air intake, grunting is a sound made during expiration to keep the airway open, and seesaw breathing is an abnormal pattern where the chest moves in while the abdomen moves out. Quivering lips are not a typical sign of impaired breathing in infants and children, making it the correct answer. Nasal flaring, grunting, and seesaw breathing are all signs indicating the need for immediate medical attention due to potential respiratory distress.
5. For a client with suspected appendicitis, in which quadrant should the nurse expect to find abdominal tenderness?
- A. upper right
- B. upper left
- C. lower right
- D. lower left
Correct answer: C
Rationale: The correct answer is C: lower right. Abdominal tenderness in the lower-right quadrant is a classic sign of appendicitis. The appendix is located in the lower right abdomen, so inflammation of the appendix typically causes tenderness in this specific area. Choices A, B, and D are incorrect because tenderness in the upper right, upper left, and lower left quadrants, respectively, is not typical in appendicitis cases. Therefore, the nurse should focus on assessing the lower right quadrant for tenderness when suspecting appendicitis.
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