NCLEX-PN
NCLEX PN 2023 Quizlet
1. Which of the following medications is not classified as a neuromuscular blocker?
- A. Anectine
- B. Pavulon
- C. Pitressin
- D. Mivacron
Correct answer: C
Rationale: The correct answer is Pitressin. Pitressin is a hormone replacement medication and is not classified as a neuromuscular blocker. Choices A, B, and D (Anectine, Pavulon, Mivacron) are neuromuscular blockers used during anesthesia to induce muscle relaxation for various procedures. Anectine is also known as succinylcholine, Pavulon is rocuronium, and Mivacron is mivacurium. These medications act on the neuromuscular junction to block the transmission of nerve impulses, leading to muscle relaxation.
2. A nurse has been ordered to set up Buck's traction on a patient's lower extremity due to a femur fracture. Which of the following applies to Buck's traction?
- A. A weight greater than 10 lbs. should be used.
- B. The line of pull is upward at an angle.
- C. The line of pull is straight
- D. A weight greater than 20 lbs. should be used.
Correct answer: C
Rationale: The correct answer is that the line of pull is straight for Buck's traction. This type of traction is applied to maintain alignment and immobilization of fractures, typically involving the lower extremities. A straight line of pull helps to provide the necessary countertraction to keep the fractured bone in proper alignment. Choices A and D are incorrect because Buck's traction commonly uses a weight range between 5-10 lbs, and using a weight greater than 10 or 20 lbs would not be appropriate or safe. Choice B is incorrect as well since the line of pull for Buck's traction is straight, not upward at an angle.
3. The client is cared for by a nurse and calls for the nurse to come to the room, expressing feeling unwell. The client's vital signs are BP: 130/88, HR: 102, RR: 28. What should the nurse do next?
- A. Administer PRN anxiolytic
- B. Administer Antibiotics
- C. Reassure the client that everything is okay and offer food and beverage
- D. Determine the Glasgow Coma Scale
Correct answer: A
Rationale: Correct! The client's vital signs indicate tachycardia and tachypnea, which could be indicative of hypoxia. Administering a PRN anxiolytic would not address the underlying issue and could mask deterioration. Reassuring the client without further assessment or intervention could lead to a delay in appropriate care if there is a serious underlying cause for the symptoms. Determining the Glasgow Coma Scale is not relevant to the client's presenting symptoms of feeling unwell and suspecting something is wrong, coupled with abnormal vital signs.
4. The client is undergoing an induction for fetal demise at 34 weeks. Immediately after delivery, the mother asks to see the infant. What is the nurse's best response?
- A. Bring the swaddled fetus to the mother
- B. Explain that the cause of death must be determined before she can see the baby
- C. Ask her if she is sure she wants to see the baby
- D. Tell her it would be better to wait until she is in her room before she sees the baby
Correct answer: A
Rationale: The nurse should bring the swaddled fetus to the mother as the best response. Allowing the mother to see the infant immediately after delivery is crucial for her grieving process. It provides her with the opportunity to bond, say goodbye, and start the grieving process. Choice B is incorrect because delaying the mother's request to see the baby can hinder her grieving process and prolong her suffering. Choice C is inappropriate as it questions the mother's decision at a sensitive time, potentially causing distress. Choice D is also not the best response as it suggests waiting, which may not be in the mother's best interest at that moment, as she needs immediate support and closure.
5. After administering enoxaparin (Lovenox) subcutaneously into the abdomen, which action should the nurse take?
- A. Gently rub the injection site after removing the needle
- B. Have the client maintain a side-lying position for at least five minutes
- C. Remove the needle and engage the needle safety device
- D. Apply heat to the injection site
Correct answer: C
Rationale: After administering a subcutaneous injection of enoxaparin (Lovenox) into the abdomen, the nurse should remove the needle and engage the needle safety device. Rubbing the injection site after the needle is withdrawn is not recommended as it may cause irritation and bruising. Having the client maintain a side-lying position for at least five minutes is unnecessary for a subcutaneous injection into the abdomen. Applying heat to the injection site is not indicated after administering enoxaparin subcutaneously; it could increase the risk of bleeding or bruising at the injection site.
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