NCLEX-PN
NCLEX PN Exam Cram
1. Which of the following arterial blood gas values indicates a patient may be experiencing a condition of metabolic acidosis?
- A. PaO2 90 mm Hg
- B. Bicarbonate 15 mEq/L
- C. CO2 47 mm Hg
- D. pH 7.34
Correct answer: B
Rationale: The correct answer is B: Bicarbonate 15 mEq/L. In metabolic acidosis, the bicarbonate levels are lower than normal. A bicarbonate value of 15 mEq/L indicates a deficit in the buffer system, contributing to the acidosis. Choices A, C, and D are incorrect. Choice A, PaO2 90 mm Hg, reflects oxygen partial pressure and is not directly related to metabolic acidosis. Choice C, CO2 47 mm Hg, represents carbon dioxide levels and is more indicative of respiratory status. Choice D, pH 7.34, falls within the normal range (7.35-7.45) and does not confirm metabolic acidosis.
2. After a left heart catheterization (LHC), a client complains of severe foot pain on the side of the femoral stick. The nurse notes pulselessness, pallor, and a cold extremity. What should the nurse's next action be?
- A. Administer an anticoagulant.
- B. Warm the room and re-assess.
- C. Increase IV fluids.
- D. Notify the physician stat.
Correct answer: D
Rationale: The correct action for the nurse to take next is to notify the physician immediately (stat). The client's symptoms of foot pain, pulselessness, pallor, and cold extremity suggest a potential vascular complication, such as arterial occlusion. Prompt notification of the physician is crucial as this condition requires urgent intervention to restore blood flow and prevent tissue damage. Administering an anticoagulant (Choice A) without physician evaluation could be harmful as the underlying cause needs to be determined first. Warming the room and re-assessing (Choice B) may delay necessary treatment. Increasing IV fluids (Choice C) is unlikely to address the urgent vascular issue indicated by the symptoms described.
3. For which adverse effect of the block does the postpartum nurse monitor the woman after receiving a subarachnoid (spinal) block for a cesarean delivery?
- A. Headache
- B. Pruritus
- C. Vomiting
- D. Hypertension
Correct answer: A
Rationale: The correct answer is 'Headache.' Postdural headache is a common adverse effect associated with a subarachnoid block due to cerebrospinal fluid leakage at the site of dural puncture. This headache worsens when the woman is upright and may improve when she lies flat. To manage this headache, bed rest and adequate hydration are recommended. Pruritus, vomiting, and hypertension are not typically associated with subarachnoid blocks. Pruritus, nausea, and vomiting are more commonly linked to the use of intrathecal opioids.
4. The client with obsessive-compulsive disorder (OCD) is asking for help with the repetitive behaviors. The nurse knows that these are a method of dealing with:
- A. Fearful situations
- B. Depression
- C. Delusions
- D. Anxiety
Correct answer: D
Rationale: The correct answer is D: Anxiety. Repetitive behaviors in OCD serve as a way for individuals to cope with their anxiety. These behaviors are often performed to reduce the distress caused by obsessive thoughts. Choice A, fearful situations, is incorrect because the behaviors are more related to managing anxiety rather than fear itself. Choice B, depression, is incorrect as OCD behaviors are not typically a method of coping with depression. Choice C, delusions, is also incorrect as these behaviors are not aimed at managing delusional thoughts but rather anxiety in OCD.
5. An infection in a central venous access device is not eliminated by giving antibiotics through the catheter. How might bacterial glycocalyx contribute to this?
- A. It protects the bacteria from antibiotic and immunologic destruction.
- B. Glycocalyx neutralizes the antibiotic, rendering it ineffective.
- C. It competes with the antibiotic for binding sites on the microbe.
- D. Glycocalyx provides nutrients for microbial growth.
Correct answer: A
Rationale: Bacterial glycocalyx is a viscous polysaccharide or polypeptide slime that covers microbes. It plays a significant role in protecting bacteria by enhancing adherence to surfaces, resisting phagocytic engulfment by white blood cells, and preventing antibiotics from contacting the microbe. Choice A is correct because glycocalyx shields the bacteria from both antibiotics and the immune system, allowing the infection to persist. Choices B, C, and D are incorrect because glycocalyx does not neutralize antibiotics, compete for binding sites with antibiotics, or provide nutrients for microbial growth.
Similar Questions
Access More Features
NCLEX PN Basic
$69.99/ 30 days
- 5,000 Questions with answers
- Comprehensive NCLEX coverage
- 30 days access
NCLEX PN Premium
$149.99/ 90 days
- 5,000 Questions with answers
- Comprehensive NCLEX coverage
- 30 days access