the mother of a toddler asks the nurse when she will know that her child is ready to start toilet training the nurse tells the mother that which obser the mother of a toddler asks the nurse when she will know that her child is ready to start toilet training the nurse tells the mother that which obser
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Nursing Elites

NCLEX NCLEX-PN

2024 PN NCLEX Questions

1. The mother of a toddler asks the nurse when she will know that her child is ready to start toilet training. The nurse tells the mother that which observation is a sign of physical readiness?

Correct answer: The child can remove his or her own clothing.

Rationale: Signs of physical readiness for toilet training include the child's ability to remove his or her own clothing. This ability indicates the child has developed the necessary fine motor skills to manage clothing during toilet training. The other choices are incorrect because temper tantrums, walking for a specific period, and using utensils are not indicators of physical readiness for toilet training.

2. A client whose right leg is in skeletal traction complains of pain in the leg. Which action should the nurse take first?

Correct answer: Realigning the client

Rationale: When a client in skeletal traction complains of pain, the priority action for the nurse is to realign the client. Severe pain may indicate the need for realignment or that the traction weights are too heavy. Realigning the client should be the initial response as it can help alleviate the pain by ensuring proper alignment. Asking the client to wiggle their toes may not address the underlying issue causing the pain. Removing traction weights should never be done unless specifically ordered by the healthcare provider as it can affect the traction's effectiveness. Medicating the client with analgesics should only be considered after attempting to address the cause of the pain, which in this case, is realignment.

3. The ICU nurse caring for a client who has just been declared brain dead can expect to find evidence of the client’s wishes regarding organ donation:

Correct answer: on the client’s driver’s license.

Rationale: In most states, indication of organ donor status is found on the client’s driver’s license, making it easily accessible for decision-making in critical situations like declaring brain death. Evidence in a last will and testament or a safety deposit box may not be promptly available. Information about organ donation is typically not included on insurance cards. The primary care physician's health record documentation could also be a relevant source for the ICU nurse. Therefore, the correct answer is finding evidence of the client’s wishes regarding organ donation on the client’s driver’s license.

4. The factor that most determines drug distribution is:

Correct answer: vascular perfusion of the tissue or organ.

Rationale: The correct answer is 'vascular perfusion of the tissue or organ.' Drug distribution is primarily determined by how well the circulatory system delivers the drug to various tissues and organs. Adequate perfusion ensures proper distribution of the drug throughout the body. While the salt form (choice B), drug interactions (choice C), and steady state (choice D) can influence drug efficacy and metabolism, they are not as crucial as vascular perfusion for the initial distribution of a drug.

5. Which of the following would likely not impede learning?

Correct answer: a client who states they are not interested

Rationale: The correct answer is a client who states they are not interested. While lack of interest can hinder learning motivation, it is not a physical or mental barrier that directly impacts the learning process. On the other hand, a client who took Ambien® an hour ago may experience drowsiness or impaired cognitive function, affecting their ability to learn. A bipolar client in a manic phase may exhibit symptoms such as racing thoughts, distractibility, and impulsivity, making it challenging for them to focus and engage in the learning process. A client with dysphagia may have difficulty swallowing, which can interfere with their ability to take oral medications or participate in activities that involve swallowing.

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