NCLEX NCLEX-PN
Nclex Practice Questions 2024
1. The nurse is assigning staff for the day. Which assignment should be given to the nursing assistant?
- A. Taking the vital signs of the 5-month-old with bronchiolitis
- B. Taking the vital signs of the 10-year-old with a 2-day postappendectomy
- C. Administering medication to the 2-year-old with periorbital cellulitis
- D. Adjusting the traction of the 1-year-old with a fractured tibia
Correct answer: Taking the vital signs of the 10-year-old with a 2-day postappendectomy
Rationale: The most appropriate assignment for a nursing assistant is to take the vital signs of a stable patient. A 10-year-old with a 2-day postappendectomy is considered stable, and routine vital signs monitoring can be safely delegated to a nursing assistant. Clients with bronchiolitis, periorbital cellulitis, and a fractured tibia require more specialized care and assessment by a licensed nurse. Bronchiolitis involves an airway alteration, periorbital cellulitis indicates an infection, and a fractured tibia may raise concerns of abuse. Therefore, options A, C, and D are incorrect for delegation to a nursing assistant.
2. A nurse is preparing to assess the dorsalis pedis pulse. The nurse palpates this pulse by placing the fingertips in which location?
- A. Behind the knee
- B. Lateral to the extensor tendon of the big toe
- C. In the groove between the malleolus and the Achilles tendon
- D. Below the inguinal ligament, halfway between the pubis and the anterior superior iliac spines
Correct answer: Lateral to the extensor tendon of the big toe
Rationale: The correct location to palpate the dorsalis pedis pulse is lateral to and parallel with the extensor tendon of the big toe. Choices A, C, and D describe the locations for other pulses - popliteal, posterior tibial, and femoral artery respectively. The popliteal pulse is found behind the knee, the posterior tibial pulse is located in the groove between the malleolus and the Achilles tendon, and the femoral artery is situated below the inguinal ligament, halfway between the pubis and the anterior superior iliac spines.
3. What is the therapeutic range for carbamazepine (Tegretol)?
- A. 7-12 mcg/mL
- B. 4-10 mcg/mL
- C. 10-14 mcg/mL
- D. 1-5 mcg/mL
Correct answer: 4-10 mcg/mL
Rationale: The therapeutic range for carbamazepine (Tegretol) is 4-10 mcg/mL. This range is established based on the optimal balance between effectiveness and safety. Choices A, C, and D are outside the therapeutic range for carbamazepine, which could lead to suboptimal treatment outcomes or increased risk of toxicity. Choice B (4-10 mcg/mL) is the correct range recommended for therapeutic efficacy while minimizing adverse effects.
4. Following a classic cholecystectomy resection for multiple stones, the PACU nurse observes serosanguinous drainage on the dressing. The most appropriate intervention is to:
- A. notify the physician of the drainage
- B. change the dressing
- C. reinforce the dressing
- D. apply an abdominal binder
Correct answer: reinforce the dressing
Rationale: In the context of a classic cholecystectomy resection, serosanguinous drainage is an expected finding postoperatively due to the nature of the surgery. The appropriate intervention in this situation is to reinforce the dressing. Changing the dressing prematurely can increase the risk of introducing infection. Applying an abdominal binder is not recommended as it can obstruct the visualization of the dressing and the underlying wound, making it difficult to monitor for any complications or changes in drainage. Notifying the physician may be necessary if there are significant changes in the drainage characteristics or other concerning signs, but the immediate action should be to reinforce the dressing to maintain a clean and secure environment for wound healing.
5. A nurse working in a pediatric clinic observes the following situations. Which of the following may indicate a delayed child to the nurse?
- A. A 12-month-old that does not 'cruise'.
- B. An 8-month-old that can sit upright unsupported.
- C. A 6-month-old that is rolling prone to supine.
- D. A 3-month-old that does not roll supine to prone.
Correct answer: A 12-month-old that does not 'cruise'.
Rationale: The correct answer is 'A 12-month-old that does not 'cruise''. At 12 months, a child should at least be 'cruising' (holding on to objects to walk), which is considered pre-walking. The other choices describe age-appropriate developmental milestones: sitting upright unsupported by 8 months, rolling prone to supine by 6 months, and rolling supine to prone by 3 months. Not 'cruising' at 12 months may indicate a delay in motor skills development.
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