NCLEX-PN
Nclex 2024 Questions
1. A client has rectal cancer and is scheduled for an abdominal perineal resection. What should be the priority nursing care during the post-op period?
- A. Teaching perineal wound care techniques
- B. Monitoring electrolyte levels
- C. Encouraging early ambulation
- D. Facilitating perineal wound drainage
Correct answer: D
Rationale: The priority nursing care during the post-op period for a client who underwent an abdominal perineal resection is to facilitate perineal wound drainage. This is crucial for preventing infection of the surgical site and promoting healing. Teaching perineal wound care techniques, as in choice A, is more appropriate than ileostomy care in this scenario. While monitoring electrolyte levels is important, it is not the priority compared to ensuring proper wound drainage, making choice B less crucial. Encouraging early ambulation, as in choice C, is beneficial but not as critical as facilitating wound drainage immediately post-op.
2. Incidences of child abuse appear to be higher in the African-American community and might be explained by:
- A. the increased number of single-parent households in African-American communities
- B. more single-parent households in African-American communities
- C. stricter child-rearing practices in African-American households
- D. a higher occurrence of rage in African Americans
Correct answer: B
Rationale: Child abuse is often associated with lower socioeconomic status and single-parent households due to increased stress and fewer support systems. Choice A is correct as single-parent households can face more challenges leading to a higher risk of child abuse. Choice B is the correct answer as it aligns with the risk factors associated with child abuse. Choice C is incorrect because there is no direct correlation between stricter child-rearing practices and child abuse rates. Choice D is incorrect because attributing child abuse to a higher occurrence of rage in African Americans is a stereotype and lacks evidence.
3. The client is admitted to the unit after a cholecystectomy. Montgomery straps are utilized with this client. The nurse is aware that Montgomery straps are utilized on this client because:
- A. The client is at risk for evisceration.
- B. The client will require frequent dressing changes.
- C. The straps provide support for drains that are inserted in the incision.
- D. No sutures or clips are used to secure the incision.
Correct answer: B
Rationale: Montgomery straps are used to secure dressings that require frequent changes due to the large amount of drainage usually present after a cholecystectomy. They are also beneficial for clients allergic to various types of tape. Answer A is incorrect as the client is not at higher risk of evisceration. Answer C is incorrect because Montgomery straps are not used to support drains. Answer D is incorrect as sutures or clips are typically used to secure the incision after gallbladder surgery, not Montgomery straps.
4. A client with acute leukemia develops a low white blood cell count. In addition to the institution of isolation, the nurse should:
- A. Request that foods be provided in sealed single-serving packages
- B. Ask the client to wear a mask when visitors are present
- C. Prep IV sites with mild soap and water and alcohol
- D. Provide foods in sealed single-serving packages
Correct answer: D
Rationale: For a client with acute leukemia and a low white blood cell count, preventing exposure to food contaminants is crucial due to immune suppression. Providing foods in sealed single-serving packages helps reduce the risk of contamination. Choice B is incorrect as it introduces the potential of infection from visitors. Choice A, suggesting disposable utensils, is not as effective as sealed containers in preventing food contamination. Choice C, using alcohol for prepping IV sites, is less suitable due to its drying effect and potential for skin breakdown, making sealed packages a better option for food safety.
5. What is a common characteristic of a batterer?
- A. Grew up in a loving, secure home
- B. Was an only child
- C. Was physically or psychologically abused
- D. Admits they have a problem with anger
Correct answer: C
Rationale: The correct answer is that a batterer is typically someone who was physically or psychologically abused. Research shows that many individuals who engage in abusive behavior report a history of being abused themselves. Choices A, B, and D are incorrect. While it is possible for a batterer to have grown up in a loving, secure home, been an only child, or acknowledge their anger issues, the most common factor associated with becoming a batterer is a history of being abused.
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