NCLEX NCLEX-PN
NCLEX PN 2023 Quizlet
1. While undergoing hemodialysis, the client becomes restless and tells the nurse he has a headache and feels nauseous. Which of the following complications does the nurse suspect?
- A. Infection.
- B. Disequilibrium syndrome.
- C. Air embolus.
- D. Infection.
Correct answer: C: Air embolus.
Rationale: In this scenario, the client undergoing hemodialysis is experiencing symptoms like restlessness, a headache, and nausea. These symptoms are indicative of an air embolus, a serious complication that can occur during hemodialysis. Air embolus happens when air enters the bloodstream and can lead to symptoms like restlessness, a headache, and nausea. It is crucial for the nurse to suspect and address this complication promptly to prevent further harm to the client. Choices A and D (Infection) are less likely in this case, as the symptoms presented are more suggestive of an air embolus rather than an infection. Choice B (Disequilibrium syndrome) is also less likely as the symptoms described are not typical of this syndrome. Therefore, the correct answer is C: Air embolus.
2. While repositioning a comatose client, the nurse senses a tingling sensation as she lowers the bed. What action should she take?
- A. Unplug the bed’s power source.
- B. Remove the client from the bed immediately.
- C. Notify the biomedical department at once.
- D. Turn off the oxygen.
Correct answer: Unplug the bed’s power source.
Rationale: The correct action for the nurse to take when sensing a tingling sensation while lowering the bed with a comatose client is to unplug the bed’s power source. This should be the initial step as there may be a fault in the bed's grounding. Removing the client from the bed immediately is not safe until the electrical issue is resolved. Notifying the biomedical department is important but should come after ensuring the immediate safety of the client. Turning off the oxygen is not necessary unless there is a specific issue related to oxygen delivery, which is not indicated in this scenario.
3. When assessing a client for risk of hyperphosphatemia, which piece of information is most important for the nurse to obtain?
- A. A history of radiation treatment in the neck region
- B. A history of recent orthopedic surgery
- C. A history of minimal physical activity
- D. A history of the client’s food intake
Correct answer: A history of radiation treatment in the neck region
Rationale: The correct answer is a history of radiation treatment in the neck region. Previous radiation to the neck may have damaged the parathyroid glands, which are crucial for calcium and phosphorus regulation. This damage can lead to disruptions in phosphorus levels, increasing the risk of hyperphosphatemia. Choices B, C, and D are not as directly related to phosphorus regulation. Orthopedic surgery, minimal physical activity, and food intake are more closely associated with calcium levels rather than phosphorus regulation. Therefore, it is essential for the nurse to focus on obtaining information about a history of radiation treatment in the neck region when assessing the risk of hyperphosphatemia in a client.
4. When caring for a Native-American family, what does the nurse need to consider?
- A. The family may consist of extended family members beyond parents and children.
- B. Native Americans tend to value their heritage and traditions.
- C. Some Native Americans use herbs and psychologic treatments for illnesses.
- D. Health care practices vary among different tribes and individuals.
Correct answer: Some Native Americans use herbs and psychologic treatments for illnesses.
Rationale: When caring for a Native-American family, it is crucial to acknowledge and respect their cultural beliefs and practices. Choice A, while relevant, is not as specific as understanding the use of herbs and psychologic treatments in Native American healing practices. Choice B, though generally true, does not directly impact the nursing care provided. Choice D, although true, is too broad and does not focus on the specific aspect of treatment practices. Choice C is the most appropriate answer as it highlights the importance of recognizing and incorporating traditional healing methods into the nursing care plan, promoting culturally sensitive and holistic care.
5. During shift change, a nurse is giving report to the oncoming LPN. Which of these is an inappropriate way to give shift report?
- A. The nurse gives report to the oncoming LPN, checking a wound vac and dressing together.
- B. The nurse reports in SBAR format, noting that the client was noncompliant with their diet during the shift.
- C. The nurse reports in the hallway, in SBAR format, and alerts the oncoming LPN about how rude the client was throughout the shift.
- D. The nurse reports at bedside with the oncoming LPN and discusses the client’s concerns after the chart has been reviewed.
Correct answer: The nurse reports in the hallway, in SBAR format, and alerts the oncoming LPN about how rude the client was throughout the shift.
Rationale: The correct answer is 'The nurse reports in the hallway, in SBAR format, and alerts the oncoming LPN about how rude the client was throughout the shift.' This choice is inappropriate because shift report should be given at the bedside, in SBAR format, and in an objective way. It is important to maintain professionalism and focus on the client's condition and care needs, rather than personal opinions or subjective comments. Reporting in the hallway may compromise patient privacy and confidentiality. Choices A, B, and D demonstrate appropriate ways of giving shift report by focusing on relevant information, using SBAR format, and discussing client concerns after reviewing the chart, which promotes effective communication and continuity of care.
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