NCLEX NCLEX-PN
NCLEX PN Practice Questions Quizlet
1. The greatest time savers when planning client care include all of the following except:
- A. reacting to the crisis of the moment
- B. setting goals
- C. planning
- D. specifying priorities
Correct answer: reacting to the crisis of the moment
Rationale: The greatest time-savers when planning client care are activities that facilitate focus and completion of priority items. Time-savers include setting goals, specifying priorities, planning tasks, delegating where appropriate, reassessment, and ongoing evaluation of needs. Reacting to the crisis of the moment is not a time-saving strategy in client care planning; it can lead to inefficiency, lack of focus, and potentially missing important priority items. Therefore, the correct answer is 'reacting to the crisis of the moment.' Choices B, C, and D are essential components for effective client care planning as they help in organizing and prioritizing tasks, setting objectives, and ensuring a structured approach to care delivery.
2. Diagnostic genetic counseling, for procedures such as amniocentesis and chorionic villus sampling, allows clients to make all of the following choices except:
- A. terminating the pregnancy.
- B. preparing for the birth of a child with special needs.
- C. accessing support services before the birth.
- D. completing the grieving process before the birth.
Correct answer: completing the grieving process before the birth.
Rationale: Diagnostic genetic counseling provides clients with important information to make informed decisions regarding their pregnancy. Clients can choose to terminate the pregnancy, prepare for the birth of a child with special needs, and access support services before the birth based on the genetic testing results. However, completing the grieving process before the birth is not a typical choice during genetic counseling. The grieving process, if needed, may extend beyond the prenatal period, especially if the findings are concerning or indicate potential issues. Therefore, completing the grieving process before the birth is the exception among the provided options.
3. A nurse in the newborn nursery, assisting with data collection for a newborn, prepares to measure the chest circumference. The nurse places the tape measure around the infant at which location?
- A. In the axillary area
- B. At the level of the nipples
- C. Two inches below the nipples
- D. At the level of the umbilicus
Correct answer: At the level of the nipples
Rationale: The chest circumference of the infant is measured at the level of the nipples. It is usually 2 to 3 cm smaller than the head circumference. The average chest circumference is 30.5 to 33 cm (12-13 inches). When there is molding of the head, the head and chest measurements may be equal at birth. Placing the tape measure at the level of the nipples ensures accuracy and consistency in newborn assessment. Options A, C, and D are incorrect as the chest circumference is specifically measured at the level of the nipples to obtain precise measurements.
4. A client is admitted to telemetry with a diagnosis of diabetes at 3pm. At 10pm, the client is unresponsive. BP is 98/64, Resp 38, HR 100, T 97. The nurse notes a fruity smell on the client’s breath. The nurse recognizes that the client is in which acid-base imbalance?
- A. Respiratory acidosis
- B. Respiratory alkalosis
- C. Metabolic acidosis
- D. Metabolic alkalosis
Correct answer: Metabolic acidosis
Rationale: Based on the client's unresponsiveness, fruity breath smell, and the presence of diabetes, the nurse can infer that the client is experiencing diabetic ketoacidosis (DKA). DKA is a complication of diabetes characterized by the accumulation of ketones in the body, leading to metabolic acidosis. The fruity breath smell is due to the presence of ketones. Therefore, the correct acid-base imbalance in this scenario is metabolic acidosis. Choice A, respiratory acidosis, is incorrect because the scenario does not provide evidence of primary respiratory dysfunction. Choice B, respiratory alkalosis, is incorrect as the client's condition does not align with the typical causes and symptoms of respiratory alkalosis. Choice D, metabolic alkalosis, is incorrect as the symptoms and history provided do not suggest a state of metabolic alkalosis.
5. A 6-month-old client is admitted with possible intussusception. Which question during the nursing history is least helpful in obtaining information regarding this diagnosis?
- A. “Tell me about his pain.”
- B. “What does his vomit look like?”
- C. “Describe his usual diet.”
- D. “Have you noticed changes in his abdominal size?”
Correct answer: “Describe his usual diet.”
Rationale: The least helpful question in obtaining information regarding intussusception is “Describe his usual diet.” This question is least relevant to the specific symptoms and presentation of intussusception. Choices A, B, and D are more directly related to symptoms commonly associated with intussusception and can provide important diagnostic clues. Asking about pain, vomit appearance, and changes in abdominal size can help in assessing the severity and progression of the condition, making them more crucial questions to ask in this scenario. Pain is a cardinal symptom of intussusception, changes in vomit appearance may indicate gastrointestinal issues, and alterations in abdominal size can signify the presence of a mass or obstruction, all of which are pertinent in diagnosing and managing intussusception.
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