NCLEX NCLEX-PN
NCLEX PN Test Bank
1. Which of these clients should the LPN/LVN see first?
- A. a client with a newly placed NG tube who is complaining of pain around the face and a plugged nose
- B. a post-op prostatectomy client who complains of bladder spasms and blood in his foley bag
- C. a client in an arm cast who is 2 days post-op and reports feelings of numbness and tingling in her affected arm
- D. a client newly diagnosed with Hepatitis A who reports stomach pain and itchy skin
Correct answer: a client in an arm cast who is 2 days post-op and reports feelings of numbness and tingling in her affected arm
Rationale: Numbness and tingling hours or days after a cast is applied may indicate compartment syndrome and should be reported to a medical provider right away. This is a potential emergency situation that requires immediate attention to prevent complications. The other options present expected or typical symptoms related to their diagnosis, which do not require immediate intervention. Complaints related to a newly placed NG tube such as pain around the face and a plugged nose may require assessment and intervention but are not as urgent as potential compartment syndrome. Bladder spasms and blood in the foley bag post-prostatectomy are common postoperative issues that can be addressed after the client in the arm cast with potential compartment syndrome is seen. Stomach pain and itchy skin in a client with Hepatitis A are common symptoms of the condition and do not indicate an emergency situation.
2. The client with diverticulosis is being assisted by the nurse in selecting appropriate foods. Which food should be avoided?
- A. Bran
- B. Fresh peaches
- C. Cucumber salad
- D. Yeast rolls
Correct answer: Cucumber salad
Rationale: The food that should be avoided for a client with diverticulosis is Cucumber salad. Foods with seeds should be avoided as they can aggravate diverticulosis by causing irritation and inflammation in the diverticula. Choices A, B, and D are allowed and even beneficial. Bran cereal and fruit like fresh peaches can help prevent constipation, which is beneficial for individuals with diverticulosis. Yeast rolls are also acceptable unless the client has specific dietary restrictions related to yeast or gluten.
3. During the history assessment of an 80-year-old client, which statement made by the client might indicate a possible fluid and electrolyte imbalance?
- A. “My skin is always so dry.”
- B. “I often use a laxative for constipation.”
- C. “I have always liked to drink a lot of iced tea.”
- D. “I sometimes have a problem with dribbling urine.”
Correct answer: “I often use a laxative for constipation.”
Rationale: The correct answer is "I often use a laxative for constipation." Frequent use of laxatives can lead to diarrhea and electrolyte loss, indicating a possible fluid and electrolyte imbalance. Statements A, C, and D are not directly related to fluid and electrolyte imbalance. Statement A about dry skin may suggest dehydration, but it is less specific to electrolyte imbalance than the frequent use of laxatives. Statement C about drinking a lot of iced tea could potentially relate to fluid intake, but it doesn't directly indicate an imbalance. Statement D about dribbling urine is more indicative of a potential urinary issue rather than a fluid and electrolyte imbalance.
4. When planning care for a client taking Heparin, which nursing diagnosis should the nurse address first?
- A. Ineffective tissue perfusion related to the presence of a thrombus obstructing blood flow
- B. Risk for injury related to active loss of blood from the vascular space
- C. Deficient knowledge related to the client's lack of understanding of the disease process
- D. Impaired skin integrity related to the development of bruises and/or hematoma
Correct answer: Risk for injury related to active loss of blood from the vascular space
Rationale: The correct answer is 'Risk for injury related to active loss of blood from the vascular space.' When a client is taking Heparin, the primary concern is the risk of bleeding due to its anticoagulant properties. Monitoring for signs of active blood loss is crucial to prevent complications like hemorrhage. While ineffective tissue perfusion, deficient knowledge, and impaired skin integrity are important, they are secondary to the immediate risk of bleeding in clients taking anticoagulants like Heparin.
5. Which of the following should be included in a diet rich in iron?
- A. peaches, eggs, beef
- B. cereals, kale, cheese
- C. red beans, enriched breads, squash
- D. legumes, green beans, eggs
Correct answer: peaches, eggs, beef
Rationale: The correct answer is peaches, eggs, beef. These are good sources of heme iron, which is more easily absorbed by the body compared to nonheme iron. Heme iron is mainly found in animal-based foods like meat, poultry, and fish. Peaches, eggs, and beef are rich in iron and can help prevent iron deficiency anemia. Choices B, C, and D are incorrect because they do not include significant sources of heme iron. Cereals, kale, cheese, red beans, enriched breads, squash, legumes, and green beans are sources of nonheme iron, which is not as efficiently absorbed by the body as heme iron. It is important to include heme iron sources in the diet for optimal iron absorption.
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