NCLEX-PN
Best NCLEX Next Gen Prep
1. The client has been on vancomycin for three days. Which of the following symptoms is least concerning?
- A. nausea
- B. headache
- C. vertigo
- D. tinnitus
Correct answer: B
Rationale: The correct answer is 'headache.' While vancomycin can cause ototoxicity leading to symptoms like tinnitus, vertigo, and nausea, headaches are not typically associated with vancomycin use. Therefore, headache is the least concerning symptom in this scenario. Nausea, vertigo, and tinnitus are more likely to be related to vancomycin ototoxicity and should be closely monitored and reported. Headache is a common symptom that may not be directly linked to vancomycin use.
2. When performing an abdominal assessment, what is the correct order of the tasks?
- A. inspect, percuss, palpate, auscultate
- B. inspect, palpate, percuss, auscultate
- C. inspect, auscultate, percuss, palpate
- D. inspect, palpate, auscultate, percuss
Correct answer: C
Rationale: The correct order of tasks when performing an abdominal assessment is to first inspect the abdomen visually, then auscultate to assess bowel sounds without altering them, followed by percussing to assess the presence of tympany or dullness, and finally palpating to feel for any tenderness, masses, or organ enlargement. Placing palpation or percussion before auscultation, as in choices A, B, and D, can affect the bowel sounds and examination findings, making them incorrect sequences.
3. The parents of a 2-year-old child ask the nurse how they can teach their child to stop taking toys away from other children. Which of the following statements by the nurse offers the parents the best explanation of their child's behavior?
- A. "Your child is egocentric. Egocentricity is normal for 2-year-old children. He believes other children want him to have their toys."?
- B. "Your child is showing negativity. He doesn't want other children to have the toys he wants."?
- C. "Your child is demonstrating magical thinking. He believes he can make the other children want him to play with their toys."?
- D. "Your child is engaging in domestic imitation. He is doing what he has seen other children do."?
Correct answer: A
Rationale: Two-year-old children are very egocentric, believing everything revolves around them. They think other children want them to have their toys, which explains why they may take toys from others. This behavior is typical for children at this age as they lack the ability to see things from another's perspective. Option B is incorrect because negativity in children this age is more related to refusal of requests rather than taking toys. Magical thinking, as described in option C, is usually seen in preschool-age children and involves unrealistic beliefs. Option D is incorrect as domestic imitation refers to imitating adult household tasks, not other children's behavior.
4. When removing hard contact lenses from an unresponsive client, what should the nurse do?
- A. Gently irrigate the eye with an irrigating solution from the inner canthus outward.
- B. Grasp the lens with a gentle pinching motion.
- C. Don sterile gloves before attempting the procedure.
- D. Ensure that the lens is centered on the cornea before gently manipulating the lids to release the lens.
Correct answer: D
Rationale: When removing hard contact lenses, it is crucial to ensure that the lens is correctly positioned on the cornea before removal. Directly grasping the lens can potentially scratch the cornea, so it is essential to gently manipulate the lids to release the lens safely. Gently irrigating the eye is unnecessary and could be harmful, especially without the client's cooperation. Wearing sterile gloves is also unnecessary for this specific procedure. Therefore, the correct approach is to ensure the proper positioning of the lens and then gently manipulate the lids to release it. Options A and C are incorrect because irrigating the eye and wearing sterile gloves are not necessary for contact lens removal. Option B is incorrect as directly grasping the lens can be harmful to the cornea.
5. The patient is inquiring about the use of a PCA pump for pain management. Which statement by the patient indicates a need for additional education?
- A. "I will continue to report my pain score during assessments."?
- B. "I understand that there is a maximum dose per hour that I can receive regardless of how many times I press the button."?
- C. "I believe this new PCA pump will finally alleviate my back pain."?
- D. "I have more control over when and how much medication I receive."?
Correct answer: C
Rationale: The correct answer is, "I believe this new PCA pump will finally alleviate my back pain."? This statement indicates a need for additional education as it reflects an unrealistic expectation regarding pain management. It is essential for the patient to understand that while a PCA pump can provide effective pain relief, it may not completely eliminate pain. Option A is correct as it demonstrates the patient's understanding of the importance of reporting pain scores for proper pain management. Option B is correct as it shows the patient's awareness of the maximum dose limits to prevent overdose. Option D is correct as it highlights the patient's understanding of the control they have over their medication administration.
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