NCLEX NCLEX-PN
NCLEX PN 2023 Quizlet
1. The client diagnosed with end-stage liver disease has completed an advance directive and a do-not-resuscitate (DNR) document and wishes to receive palliative care. Which of the following would correspond to the client’s wish for comfort care?
- A. Positioning frequently to prevent skin breakdown and providing pain management and other comfort measures
- B. Carrying out vigorous resuscitation efforts if the client were to stop breathing, but no resuscitation if the heart stops beating
- C. Providing intravenous fluids when the client becomes dehydrated
- D. Providing total parenteral nutrition (TPN) if the client is not able to eat
Correct answer: Positioning frequently to prevent skin breakdown and providing pain management and other comfort measures
Rationale: Palliative care includes measures to prevent skin breakdown, pain management, and management of other symptoms that cause discomfort, as well as encouraging contact with family and friends. A DNR request precludes all resuscitative efforts related to respiratory or cardiac arrest, making choice B incorrect. Dehydration is a natural part of the dying process, so providing intravenous fluids as in choice C would not align with the client's wish for comfort care. Total parenteral nutrition (TPN) as in choice D is an invasive procedure meant to prolong life and is not part of palliative care, which focuses on improving quality of life rather than extending it.
2. A young boy is recently diagnosed with a seizure disorder. Which of the following statements by the boy’s mother indicates a need for further teaching by the nurse?
- A. “I should make sure he gets plenty of rest.”
- B. “I should get him a medical alert bracelet.”
- C. “I should lay him on his back during a seizure.”
- D. “I should loosen his clothing during a seizure.”
Correct answer: “I should lay him on his back during a seizure.”
Rationale: The correct answer is “I should lay him on his back during a seizure.” This statement indicates a need for further teaching because a client having a seizure should be turned to the side to prevent aspiration of secretions. Choices A, B, and D are correct. Getting plenty of rest helps in managing seizures, having a medical alert bracelet informs others about the condition in case of emergency, and loosening clothing during a seizure ensures better air circulation and prevents injury. These actions demonstrate adequate understanding of the teaching provided.
3. While caring for the following clients, a pediatric nurse tells the charge nurse she must leave due to a family emergency. Which client would the charge nurse reassign to an LPN?
- A. An eight-year-old in diabetic ketoacidosis
- B. A six-year-old in sickle cell crisis
- C. A two-month-old with dehydration
- D. A five-year-old in skeletal traction
Correct answer: A five-year-old in skeletal traction
Rationale: The correct answer is a five-year-old in skeletal traction. This task is within the scope of practice for an LPN and would need minimal assistance from an RN. The children with diabetic ketoacidosis, sickle cell crisis, and dehydration require close observation, good assessment skills, IVF needs, and medications that would be better managed by an RN. Reassigning the child in skeletal traction to an LPN ensures appropriate care while allowing the RN to focus on the more critical cases.
4. The nurse receives an assignment of three clients. Which of the following should the nurse consider as the highest priority when determining which client to assess first?
- A. the client who most recently rang their call bell
- B. the client who has been waiting the longest for their call bell to be answered
- C. the client who is in the most pain
- D. the client who may have a risk for an airway obstruction
Correct answer: the client who may have a risk for an airway obstruction
Rationale: The nurse should prioritize assessing a client with a potential airway obstruction first based on the ABCs (airway, breathing, circulation) principle. Maintaining a clear airway is crucial for oxygenation and ventilation, making it the highest priority. Choices A and B focus on call bells and waiting times, which are important but not life-threatening in comparison to airway concerns. While pain management is essential, it takes precedence after addressing immediate life-threatening issues like airway compromise.
5. While assessing for costovertebral angle tenderness, a nurse percusses the area, and the client complains of sharp pain. The nurse interprets this finding as most indicative of which disorder?
- A. Liver enlargement
- B. Ovarian infection
- C. Spleen enlargement
- D. Kidney inflammation
Correct answer: D: Kidney inflammation
Rationale: When assessing for costovertebral angle tenderness, sharp pain on percussion of the area indicates inflammation of the kidney or paranephric area. The correct technique involves placing one hand over the 12th rib, at the costovertebral angle, and thumping that hand with the ulnar edge of the other fist. The client normally feels a thud and should not experience pain. Ovarian infection, liver enlargement, or spleen enlargement are not associated with the costovertebral angle tenderness. Therefore, the correct answer is kidney inflammation.
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