NCLEX NCLEX-PN
Nclex 2024 Questions
1. Which of the following roommates would be best for the client newly admitted with gastric resection?
- A. A client with Crohn’s disease
- B. A client with pneumonia
- C. A client with gastritis
- D. A client with phlebitis
Correct answer: A client with phlebitis
Rationale: The most suitable roommate for the client newly admitted with gastric resection is the client with phlebitis. Phlebitis is an inflammation of the blood vessel and is not infectious, making it a safer option for the surgical client. Crohn’s disease clients (choice A) have frequent stools that might spread infections to the surgical client, posing a risk. A client with pneumonia (choice B) is coughing, which can disturb the gastric client's recovery. Additionally, a client with gastritis (choice C) who is vomiting and experiencing diarrhea would also not be an ideal roommate for a client recovering from gastric resection.
2. A nurse is performing suctioning through an adult client’s tracheostomy tube. The nurse notes that the client’s oxygen saturation is 89% and terminates the procedure. Which action would the nurse take next?
- A. Rechecking the pulse oximetry reading
- B. Calling the respiratory therapist
- C. Calling the healthcare provider
- D. Oxygenating the client with 100% oxygen
Correct answer: Oxygenating the client with 100% oxygen
Rationale: The nurse should monitor the client’s heart rate and pulse oximetry during suctioning to assess the client’s tolerance of the procedure. Oxygen desaturation to below 90% indicates hypoxemia. If hypoxia occurs during suctioning, the nurse must terminate the procedure and oxygenate the client with 100% oxygen to address the hypoxemia promptly and ensure the client's safety. Rechecking the pulse oximetry reading is important, but the priority is to address the hypoxemia by providing oxygen. Contacting the healthcare provider or respiratory therapist is not necessary at this time as the nurse can manage the hypoxemia with oxygenation. Oxygenating the client with 100% oxygen is the immediate action required in this situation.
3. A man reports his wife is constantly cleaning, which interferes with family life. Friends avoid visiting due to feeling uncomfortable. The husband finds her cleaning even at night. The nurse should consult and recommend the husband help with therapy by:
- A. telling his wife to stop cleaning whenever he notices her actions.
- B. making a baseline record of the time the wife spends cleaning.
- C. decreasing the stimuli in the home.
- D. helping his wife with the cleaning.
Correct answer: decreasing the stimuli in the home.
Rationale: The correct answer is to decrease the stimuli in the home. The wife's behavior suggests obsessive-compulsive disorder, an anxiety disorder. By reducing stimuli in the environment, such as clutter or triggers that prompt cleaning, it helps in managing the condition and promoting a calmer atmosphere. Option A is incorrect as directly telling the wife to stop can escalate her anxiety. Option B is not the priority initially, as addressing the root cause is more crucial. Option D may reinforce the behavior rather than addressing the underlying issue.
4. The nurse is preparing for a dressing change on a full thickness burn to the flank area. The orders include irrigating the wound with each dressing change. To irrigate the wound, what will the nurse use?
- A. Sterile saline
- B. Distilled water
- C. Betadine scrub
- D. Tap water
Correct answer: A
Rationale: When irrigating a wound, especially in the case of a full-thickness burn, it is crucial to use a solution that is gentle and non-irritating to the tissues. Sterile saline is the preferred choice for wound irrigation as it is isotonic and does not cause additional damage to the already compromised tissue. Distilled water lacks the electrolytes present in saline, Betadine scrub is not used for irrigation due to its potential to be cytotoxic, and tap water may introduce contaminants and microorganisms to the wound.
5. In a community pediatric health clinic, which developmental task should you apply into your practice?
- A. You should apply the principles of initiative when caring for preschool children.
- B. You should apply the principles of sensorimotor thought when caring for preschool children.
- C. You should apply the principles of intimacy when caring for the adolescent.
- D. You should apply the principles of concrete operations when caring for the adolescent.
Correct answer: You should apply the principles of initiative when caring for preschool children.
Rationale: When working in a community pediatric health clinic, applying the principles of initiative is crucial when caring for preschool children. According to Erik Erikson's psychosocial theory, the developmental task for preschool children is initiative. Preschool children are in the stage where they are eager to initiate activities and carry out tasks. This stage is characterized by a balance between initiative and guilt. By encouraging children to explore and take the initiative in a supportive environment, healthcare providers can foster their sense of independence and creativity. The other choices are incorrect because: - Sensorimotor thought is a term associated with Jean Piaget's cognitive development theory, not Erikson's psychosocial theory. - Intimacy is a developmental task associated with young adults, not adolescents, in Erikson's theory. - Concrete operations is a term linked to Piaget's theory of cognitive development and is not a developmental task according to Erikson's psychosocial theory.
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