NCLEX-PN
NCLEX PN Exam Cram
1. Which statement best describes electrolytes in intracellular and extracellular fluid?
- A. There is a greater concentration of sodium in extracellular fluid and potassium in intracellular fluid
- B. There is an equal concentration of sodium and potassium in extracellular fluid
- C. There is a greater concentration of potassium in extracellular fluid and sodium in intracellular fluid
- D. There is an equal concentration of sodium and potassium between intracellular and extracellular fluid
Correct answer: A
Rationale: Electrolytes are distributed unequally between intracellular and extracellular fluids. Sodium concentration is higher in extracellular fluid, while potassium concentration is higher in intracellular fluid. Therefore, the correct answer is 'There is a greater concentration of sodium in extracellular fluid and potassium in intracellular fluid.' Choices B, C, and D are incorrect because they do not accurately describe the typical distribution of sodium and potassium between intracellular and extracellular fluid.
2. A patient 3 hours post-op from a hysterectomy is complaining of intense pain at the incision site. When assessing the patient, the nurse notes a BP of 169/93, pulse 145 bpm, and regular. What action should the nurse take?
- A. Reassure the patient that pain is normal following surgery.
- B. Administer prn Nifedipine and assess the client's response.
- C. Administer prn Meperidine HCL and assess the client's response.
- D. Recheck BP and pulse rate every 20 minutes for the next hour.
Correct answer: C
Rationale: The correct action for the nurse to take in this situation is to administer prn Meperidine HCL and assess the client's response. A BP of 169/93 and a pulse of 145 bpm indicate pain-related hypertension and sinus tachycardia, which are physiological responses to pain. Treating the cause of the increased pulse rate requires pain medication. Reassuring the patient about normal post-surgery pain is important, but addressing the physiological responses to pain is a priority. Administering Nifedipine, a calcium channel blocker, is not indicated for pain management but for hypertension. Rechecking the BP and pulse rate without addressing the pain directly does not address the underlying issue causing the elevated vital signs.
3. A nurse is covering a pediatric unit and is responsible for a 15-year-old male patient on the floor. The mother of the child states, "I think my son is sexually interested in girls."? The most appropriate course of action for the nurse is to respond by stating:
- A. "I will talk to the doctor about it."?
- B. "Has this been going on for a while?"?
- C. "How do you know this?"?
- D. "Teenagers often exhibit signs of sexual interest in females."?
Correct answer: D
Rationale: The most appropriate response for the nurse in this situation is to acknowledge that teenagers often exhibit signs of sexual interest in females. This response normalizes the mother's concern and provides reassurance that such behavior is typical during adolescence. Option A deflects the conversation to the doctor without addressing the mother's concern directly. Option B focuses on the duration rather than addressing the mother's statement. Option C may come off as defensive or dismissive, questioning the mother's observation. Therefore, the best response is to acknowledge the normalcy of teenage behavior regarding sexual interest.
4. A client receiving drug therapy with furosemide and digitalis requires careful observation and care. In planning care for this client, the nurse should recognize that which of the following electrolyte imbalances is most likely to occur?
- A. hyperkalemia
- B. hypernatremia
- C. hypokalemia
- D. hypomagnesemia
Correct answer: C
Rationale: When a client is receiving drug therapy with furosemide and digitalis, the nurse should anticipate the development of hypokalemia due to the potassium-wasting effects of furosemide. Hypokalemia can potentiate digitalis toxicity. While hyperkalemia is a concern with some medications, it is not typically associated with furosemide and digitalis. Furosemide can lead to hyponatremia, not hypernatremia, due to its diuretic effect. Hypomagnesemia, though a possible imbalance, is not the most likely to occur in this scenario as furosemide and digitalis are more commonly associated with hypokalemia.
5. When teaching a client about anti-retroviral therapy for human immunodeficiency virus (HIV), the PN should emphasize:
- A. When started, therapy must not be interrupted to prevent viral resistance.
- B. When started, therapy must not be interrupted to prevent opportunistic infection.
- C. Therapy should not be interrupted for one day each month to prevent toxicity.
- D. Therapy should not be interrupted for one week every three months to prevent toxicity.
Correct answer: A
Rationale: When teaching a client about anti-retroviral therapy for HIV, it is crucial to emphasize that therapy must not be interrupted to prevent viral resistance. HIV mutates rapidly, and any interruption can lead to the emergence of resistant strains, compromising treatment effectiveness. Choice B is incorrect because keeping the virus in check with anti-retrovirals helps the client's immune system fight off opportunistic infections. Choices C and D are incorrect because therapy should not be interrupted for any reason. If toxicity occurs, the healthcare provider may adjust the treatment regimen by prescribing alternative anti-retroviral drugs.
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