NCLEX-PN
Quizlet NCLEX PN 2023
1. When giving an intramuscular injection to an infant, which of the following sites is preferred?
- A. Ventrogluteal region
- B. Deltoid
- C. Vastus lateralis
- D. Dorsogluteal region
Correct answer: C
Rationale: The correct answer is the Vastus lateralis when giving an intramuscular injection to an infant. The Vastus lateralis muscle, located in the thigh, is the preferred site for infants as it has a larger muscle mass and is well-developed, making it suitable for injections. The Ventrogluteal region and Dorsogluteal region are not recommended for infants due to their smaller muscle mass and potential risk of damaging nearby structures. The Deltoid muscle is typically used for older children and adults, not infants.
2. A client who is newly diagnosed with Parkinson's disease and beginning medication therapy asks the nurse, 'How soon will I see improvement?' The nurse's best response is:
- A. "That varies from client to client."?
- B. "You should discuss that with your physician."?
- C. "You should notice a difference in a few days."?
- D. "It might take several weeks before you notice improvement."?
Correct answer: D
Rationale: In the case of Parkinson's disease, improvement in symptoms may take several weeks of therapy to become noticeable. Therefore, the correct answer is to inform the client that it might take several weeks before they notice improvement. Choice A acknowledges individual variability but does not provide a specific timeframe, making it less reassuring. Choice B suggests deferring the question to the physician, which is not the most supportive response. Choice C is incorrect because improvement in Parkinson's disease symptoms typically does not occur within a few days.
3. What is pica?
- A. dependency on alcohol
- B. increased iron in the diet
- C. the sickle cell trait
- D. eating ice
Correct answer: D
Rationale: Pica is a disorder characterized by the ingestion of nonfood substances, which can lead to a clinical iron deficiency. It may be the first sign of an underlying issue. Individuals with pica consume a variety of nonfood items such as ice, clay, dirt, or paste. Choice A, dependency on alcohol, is incorrect as it is not related to pica. Choice B, increased iron in the diet, is incorrect because pica involves ingesting nonfood items rather than having an increased intake of iron. Choice C, the sickle cell trait, is unrelated to pica and is therefore incorrect.
4. The schizophrenic client tells you that they are "Jesus"? and "there to save the world"?. They are reading from the Bible and warning others of hell and damnation. The whole unit is getting upset and several are beginning to cry. What should the nurse do at this time?
- A. Set limits and send the client to their room.
- B. Explain to the client that not all people are Christians.
- C. Remove the Bible from the client and explain that they are not "Jesus"?.
- D. Ask the client to share with the group how he knows that he is "Jesus"?.
Correct answer: A
Rationale: In this situation, the most appropriate action for the nurse to take is to set limits with the client and redirect them to their room. The client's behavior is disruptive and causing distress among others in the unit. Sending the client to their room allows them to cool down and prevents further agitation among other patients. Removing the client from the current environment can help de-escalate the situation. Asking the client to share how they know they are "Jesus"? (Choice D) may further agitate the situation and is not the immediate priority. Explaining to the client that not all people are Christians (Choice B) may not effectively address the disruptive behavior. Removing the Bible from the client (Choice C) without addressing the underlying issue may escalate the situation further.
5. The client seeks advice from the nurse regarding issues with flatus due to colostomy. Which food should the nurse recommend?
- A. High-fiber foods, such as bran.
- B. Cruciferous vegetables, such as cabbage, broccoli, and kale.
- C. Carbonated beverages.
- D. Yogurt.
Correct answer: D
Rationale: The correct answer is yogurt. Yogurt can help reduce gas formation in clients with a colostomy. High-fiber foods like bran can stimulate peristalsis and increase flatulence, which is not helpful in this situation. Cruciferous vegetables, such as cabbage, broccoli, and kale, and beans tend to increase gas formation. Carbonated beverages, along with smoking, chewing gum, and drinking fluids with a straw, can also increase gas formation. Therefore, the nurse should recommend yogurt to help alleviate the client's issues with flatus.
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