NCLEX NCLEX-PN
Nclex Exam Cram Practice Questions
1. Which of the following might be an appropriate nursing diagnosis for an epileptic client?
- A. Dysreflexia
- B. Risk for Injury
- C. Urinary Retention
- D. Unbalanced Nutrition
Correct answer: Risk for Injury
Rationale: The correct nursing diagnosis for an epileptic client would be 'Risk for Injury' as the client is prone to injuries during seizure activity, such as head trauma from falls. Epilepsy does not typically cause dysreflexia. While urinary retention may occur during or after a seizure, it is not a common nursing diagnosis related to epilepsy. 'Unbalanced Nutrition' is not a priority nursing diagnosis for an epileptic client compared to the immediate risk of injury during seizures.
2. When dressing a severe burn to the right hand, it is important for the nurse to:
- A. Apply a wet-to-dry dressing for debridement
- B. Wrap each digit individually to prevent webbing
- C. Open blisters to allow drainage prior to dressing
- D. Allow the client to do as much of the dressing change as possible
Correct answer: Wrap each digit individually to prevent webbing
Rationale: When dressing a severe burn to the hand, it is crucial to wrap each digit individually to prevent webbing, which can lead to contractures and impaired function. Applying a wet-to-dry dressing for debridement is not recommended for burn wounds as it can cause trauma to the wound bed during removal. Opening blisters can increase the risk of infection and delay healing. Allowing the client to perform the dressing change may not ensure proper care and can lead to complications.
3. Which of the following devices may be applicable to a bedridden patient to address potential venous insufficiency? Choose all that apply.
- A. Shear-reducing mattress
- B. Sequential compression devices
- C. Compression stockings
- D. Non-skid socks
Correct answer: B and C
Rationale: For a bedridden patient with potential venous insufficiency, sequential compression devices (SCDs) and compression stockings are appropriate choices. SCDs help improve venous return from the lower extremities by applying sequential pressure, aiding circulation. Compression stockings also assist in preventing blood from pooling in the legs by applying pressure to support venous return. Shear-reducing mattresses are not directly related to managing venous insufficiency, as they are designed to reduce friction and shear forces on the skin to prevent pressure ulcers. Non-skid socks are primarily used for fall prevention and have no direct impact on venous insufficiency.
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: Bring the swaddled fetus to the mother
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. Signs of impaired breathing in infants and children include all of the following except:
- A. nasal flaring
- B. grunting
- C. seesaw breathing
- D. quivering lips
Correct answer: quivering lips
Rationale: Signs of impaired breathing in infants and children typically include nasal flaring, grunting, and seesaw breathing. Nasal flaring is the widening of the nostrils during breathing to help with air intake, grunting is a sound made during expiration to keep the airway open, and seesaw breathing is an abnormal pattern where the chest moves in while the abdomen moves out. Quivering lips are not a typical sign of impaired breathing in infants and children, making it the correct answer. Nasal flaring, grunting, and seesaw breathing are all signs indicating the need for immediate medical attention due to potential respiratory distress.
Similar Questions
Access More Features
NCLEX Basic
- 5,000 Questions with answers
- Comprehensive NCLEX coverage
- 30 days access @ $69.99
NCLEX Basic
- 5,000 Questions and answers
- Comprehensive NCLEX Coverage
- 90 days access @ $69.99