NCLEX NCLEX-PN
Nclex 2024 Questions
1. The client is admitted to the unit after a cholecystectomy. Montgomery straps are utilized with this client. The nurse is aware that Montgomery straps are utilized on this client because:
- A. The client is at risk for evisceration.
- B. The client will require frequent dressing changes.
- C. The straps provide support for drains that are inserted in the incision.
- D. No sutures or clips are used to secure the incision.
Correct answer: The client will require frequent dressing changes.
Rationale: Montgomery straps are used to secure dressings that require frequent changes due to the large amount of drainage usually present after a cholecystectomy. They are also beneficial for clients allergic to various types of tape. Answer A is incorrect as the client is not at higher risk of evisceration. Answer C is incorrect because Montgomery straps are not used to support drains. Answer D is incorrect as sutures or clips are typically used to secure the incision after gallbladder surgery, not Montgomery straps.
2. The LPN is preparing a client for discharge, and the discharge medications include phenobarbital. Which of these client statements would indicate a need for reinforced teaching about this medication?
- A. “I will need to avoid eating excessive leafy greens.”
- B. “It’s best to take this medication with food.”
- C. “I can’t wait to get back to my nightly glass of wine.”
- D. “I should try to take this medication at the same time every day.”
Correct answer: “I can’t wait to get back to my nightly glass of wine.”
Rationale: The correct answer is, “I can’t wait to get back to my nightly glass of wine,” as phenobarbital should not be taken with alcohol as it is a barbiturate. Alcohol may increase the sedative effect, posing risks to the patient's safety. Choice A, “I will need to avoid eating excessive leafy greens,” is unrelated to phenobarbital and not a cause for reinforced teaching. Choice B, “It’s best to take this medication with food,” is a general instruction and not specific to phenobarbital. Choice D, “I should try to take this medication at the same time every day,” is a common recommendation for medication adherence but does not highlight a specific concern related to phenobarbital.
3. When an elder client asks the nurse whether he will be capable of sexual activity in old age, the best response by the nurse is:
- A. “Elder adults are psychologically and physically capable of engaging in sexual activity regardless of age-related changes.”
- B. “If you haven’t been sexually active throughout your life, you will not be able to participate in sexual activity in old age.”
- C. “When intercourse isn’t possible, many of your sexual needs can be met through intimacy and touch.”
- D. “You might find it takes longer for you to achieve an erection, but you can maintain it for a longer time.”
Correct answer: “Elder adults are psychologically and physically capable of engaging in sexual activity regardless of age-related changes.”
Rationale: The best response for the nurse when an elder client asks about capability for sexual activity in old age is to provide reassurance and open communication. Choice A is the correct answer as it acknowledges that elder adults can engage in sexual activity both physically and psychologically despite age-related changes. This response encourages further discussion and addresses the client's concerns. Choices B, C, and D contain some truths but are not the most therapeutic responses. Choice B implies that past sexual activity is a prerequisite for sexual activity in old age, which is not entirely accurate as intimacy can be experienced in various ways. Choice C, while true about alternative ways to meet sexual needs, does not directly address the client's question about sexual activity. Choice D focuses on the physiological aspect of sexual function, which is important but not the most appropriate initial response to the client's query.
4. How should a client's neck be positioned for palpation of the thyroid?
- A. flexed toward the side being examined
- B. hyperextended directly backward
- C. flexed away from the side being examined
- D. flexed directly forward
Correct answer: flexed toward the side being examined
Rationale: The correct way to position a client's neck for palpation of the thyroid is to have it flexed toward the side being examined. This positioning helps to better access and palpate the thyroid gland. Option B, hyperextending the neck directly backward, is incorrect as it can make palpation more difficult and uncomfortable for the client. Option C, flexing the neck away from the side being examined, is also incorrect as it may obscure the thyroid gland, making it harder to palpate. Option D, flexing the neck directly forward, is not ideal for thyroid palpation as it does not provide the best access to the gland.
5. The physician has prescribed tranylcypromine sulfate (Parnate) 10mg bid. The nurse should teach the client to refrain from eating foods containing tyramine because it may cause:
- A. Hypertension
- B. Hyperthermia
- C. Melanoma
- D. Urinary retention
Correct answer: Hypertension
Rationale: If the client eats foods high in tyramine, he might experience malignant hypertension. Tyramine is found in cheese, sour cream, Chianti wine, sherry, beer, pickled herring, liver, canned figs, raisins, bananas, avocados, chocolate, soy sauce, fava beans, and yeast. These episodes are treated with Regitine, an alpha-adrenergic blocking agent. Choices B, C, and D are unrelated to the question: Hyperthermia is excessive body temperature, melanoma is a type of skin cancer, and urinary retention is the inability to empty the bladder.
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