NCLEX-PN
2024 PN NCLEX Questions
1. A nurse is determining the fetal heart rate (FHR) and places the fetoscope on the mother's abdomen to count the FHR. The nurse simultaneously palpates the mother's radial pulse and notes that it is synchronized with the sounds heard through the fetoscope. Which action should the nurse take?
- A. Count the FHR for 60 seconds, ensuring that it is synchronized consistently with the mother's radial pulse.
- B. Move the fetoscope to another area on the mother's abdomen to locate the fetal heart.
- C. Ask the mother to lie still while both the FHR and the radial pulse rate are counted.
- D. Count the FHR for 30 seconds and then count the radial pulse rate of the mother for 30 seconds.
Correct answer: B
Rationale: When auscultating the fetal heart rate, the nurse would place the fetoscope on the maternal abdomen, over the fetal back. The nurse would then palpate the mother's radial pulse. If her pulse is synchronized with the sounds from the fetoscope, the nurse would move the fetoscope to another area on the mother's abdomen to locate the FHR. The nurse needs to be sure that the FHR is what is actually being heard. Other sounds that may be heard are the funic sound (blood flowing through the umbilical cord) and the uterine sound (blood flowing through the uterine vessels). The funic sound is synchronized with the FHR; the uterine sound is synchronized with the mother's pulse. Therefore, moving the fetoscope to a different area will help in accurately locating and counting the fetal heart rate. Choice A is incorrect because counting for 60 seconds without changing the position may not address the issue of accurately locating the FHR. Choice C is incorrect as it does not address the need to reposition the fetoscope to locate the fetal heart. Choice D is incorrect because counting the FHR and the radial pulse rate separately may not help in differentiating the two sounds.
2. Distribution of a drug to various tissues depends on the amount of cardiac output to each type of tissue. Which tissue would receive the highest amount of cardiac output and thus the highest amount of a drug?
- A. skin
- B. adipose tissue
- C. skeletal muscle
- D. myocardium
Correct answer: D
Rationale: The tissue that would receive the highest amount of cardiac output and thus the highest amount of a drug is the myocardium. Highly perfused tissues include vital organs like the brain, heart, kidneys, adrenal glands, and liver. The myocardium, being part of the heart, receives a significant amount of cardiac output. Choices A (skin) and B (adipose tissue) are poorly perfused tissues and would not receive high amounts of cardiac output. Choice C (skeletal muscle) is also less perfused compared to the myocardium.
3. The client should include all of the following in teaching an obese client about nutritional needs and weight loss except:
- A. knowledge of food and food products
- B. development of a positive mental attitude
- C. adequate exercise
- D. starting a fast weight-loss diet
Correct answer: D
Rationale: When educating an obese client about nutritional needs and weight loss, it is crucial to emphasize a holistic approach that involves understanding food and food products, fostering a positive mental attitude, and incorporating adequate exercise. Initiating a fast weight-loss diet is not advisable due to potential health risks and lack of long-term sustainability. Therefore, this option stands out as the exception and should not be part of the client's learning. Choices A, B, and C are essential components of a healthy weight-loss plan and should be included in the client's education.
4. The nurse notes that a client in later adulthood has tremors of the hands. Based on this finding, what action should the nurse take?
- A. Ask the healthcare provider about referring the client to a neurological specialist.
- B. Obtain a prescription for a muscle relaxant.
- C. Notify the healthcare provider immediately.
- D. Document the findings.
Correct answer: D
Rationale: When a nurse observes senile tremors, such as intentional tremor of the hands in a client in later adulthood, it is important to document the findings. Senile tremors are benign and a normal age-related occurrence. Referring the client to a neurological specialist (Choice A) is unnecessary as senile tremors do not require specialized neurological intervention. Prescribing a muscle relaxant (Choice B) is not indicated since senile tremors are benign and not typically treated with muscle relaxants. Notifying the healthcare provider immediately (Choice C) is unnecessary as senile tremors do not require urgent intervention. Therefore, the most appropriate action is to document the findings (Choice D) for the client's medical record and to establish a baseline for future assessments.
5. When assisting with data collection on language development in a toddler from a bilingual family, what characteristic would a nurse expect?
- A. Is more advanced than expected
- B. Is developing as expected
- C. Is slower than expected
- D. Will require assistance from a speech therapist
Correct answer: C
Rationale: When assessing language development in a toddler from a bilingual family, a nurse would expect the child's language development to be slower than expected. Various factors, such as physical maturity and reinforcement received, can influence the pace of language development. Children from bilingual families, twins, and non-firstborn children may exhibit slower language development. Therefore, it is common for the language development of a toddler from a bilingual family to be slower than expected. This characteristic does not necessarily imply a need for speech therapy. Choices A, B, and D are incorrect because, in this context, the language development of the child is more likely to be slower than expected rather than more advanced, developing as expected, or requiring speech therapy.
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