NCLEX-PN
NCLEX PN 2023 Quizlet
1. Which of the following organs of the digestive system has a primary function of absorption?
- A. stomach
- B. pancreas
- C. small intestine
- D. gallbladder
Correct answer: C
Rationale: The small intestine is the correct answer. It is the primary organ responsible for absorption in the digestive system. The stomach's primary function is to break down food through mechanical and chemical digestion. The pancreas produces digestive enzymes to aid in the breakdown of food. The gallbladder stores bile produced by the liver, which helps in the digestion of fats. However, neither the stomach, pancreas, nor gallbladder play the primary role of absorption in the digestive process, making them incorrect choices.
2. A nurse assesses an 83-year-old female's venous ulcer for the second time that is located near the right medial malleolus. The wound is exhibiting purulent drainage, and the patient has limited mobility in her home. Which of the following is the best course of action?
- A. Encourage warm water soaks to the right foot.
- B. Notify the case manager of the purulent drainage.
- C. Determine the patient's pulse in the right ankle.
- D. Recommend increased activity to reduce the purulent drainage.
Correct answer: A
Rationale: The correct course of action is to encourage warm water soaks to the right foot. This can help promote wound healing and alleviate discomfort. Before recommending increased activity or notifying additional team members, it is crucial to assess arterial blood flow by determining the patient's pulse in the right ankle. Poor arterial blood flow could worsen the condition, making increased activity inappropriate. While notifying the case manager of purulent drainage is important, addressing the wound care directly should be the primary focus at this stage.
3. Following a thyroidectomy, a client is complaining of shortness of breath (SOB) and neck pressure. Which nursing action is the best response?
- A. Stay with the client, remove the dressing, and elevate the head of bed.
- B. Call a code, open the trach set, and position the client supine.
- C. Have the client say "EEE"? to check for laryngeal integrity.
- D. Immediately go to the nurse's station and call the physician
Correct answer: A
Rationale: Correct! The client is displaying signs of respiratory distress after a thyroidectomy. By staying with the client, removing the dressing around the neck, and elevating the head of the bed, the nurse can assess the airway and breathing status more effectively. This immediate action can help alleviate any potential airway obstruction. Choice B is incorrect because calling a code and opening the trach set without initial assessment and basic interventions may delay necessary actions. Choice C is incorrect as having the client say "EEE"? is not as immediate or effective in addressing the respiratory distress. Choice D is incorrect as leaving the client alone and calling the physician without providing immediate assistance can be detrimental in a situation of potential airway compromise.
4. The client is preparing to undergo a total hysterectomy for advanced cervical cancer. The client is crying and says that she wants to have more children and is unsure if she should have the procedure. What should the nurse do?
- A. Allow the client to honestly discuss her fears and encourage her to talk more with her physician.
- B. Tell her the good things that she will be able to do without more children and encourage her to make a list of positive things.
- C. Explain to the client that her ovaries can be frozen for egg harvesting at a later time and she can find a surrogate.
- D. Advise the client to put off having the surgery until she is sure that she wants to undergo the procedure and notify the surgeon of the decision.
Correct answer: A
Rationale: In this situation, the most appropriate action for the nurse is to allow the client to express her fears and concerns openly. By encouraging her to talk more with her physician, the nurse is promoting effective communication and ensuring that the client receives adequate information to make an informed decision. Option A is correct because it acknowledges the client's emotions and empowers her to seek clarification and support from her healthcare provider. Options B and C do not address the client's emotional needs or provide a solution to her concerns regarding fertility. Option D is not appropriate as it does not prioritize the client's emotional well-being and delays necessary medical treatment for advanced cervical cancer.
5. A healthcare provider is caring for a patient who has experienced burns to the right lower extremity. According to the Rule of Nines, which of the following percentages most accurately describes the severity of the injury?
- A. 36%
- B. 27%
- C. 18%
- D. 9%
Correct answer: C
Rationale: According to the Rule of Nines, the right lower extremity accounts for 18% of the total body surface area. The Rule of Nines divides the body into regions, each representing 9% or a multiple of 9%, allowing for a quick estimation of the extent of burns. In this case, the correct answer is 18% as it corresponds to the percentage allocated for each lower extremity. Choices A, B, and D are incorrect as they do not match the standard allocation for the right lower extremity in the Rule of Nines.
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