NCLEX-PN
NCLEX PN Exam Cram
1. A person who had a left CVA and right lower extremity hemiparesis is being instructed by a nurse to use a quad cane. Which of the following is the most appropriate gait sequence?
- A. Place the cane in the patient's left upper extremity, encourage cane, then right lower extremity, then left upper extremity gait sequence.
- B. Place the cane in the patient's left upper extremity, encourage cane, then left lower extremity, then right upper extremity gait sequence.
- C. Place the cane in the patient's right upper extremity, encourage cane, then right lower extremity, then left upper extremity gait sequence.
- D. Place the cane in the patient's right upper extremity, encourage cane, then left lower extremity, then right upper extremity gait sequence.
Correct answer: A
Rationale: The correct gait sequence for a person with left CVA and right lower extremity hemiparesis using a quad cane is to place the cane in the patient's strong upper extremity, which is the left upper extremity in this case. The correct sequence should be right lower extremity followed by left upper extremity, as this pattern mimics a normal gait pattern. Therefore, Choice A is the correct answer. Choices B, C, and D are incorrect because they do not follow the proper gait sequence for this specific patient's condition. The cane should be placed in the strong upper extremity, and the affected lower extremity should move first to provide stability and support, which is essential in this situation.
2. A young female teenager describes a brutal assault and rape to the nurse on duty. Which of the following actions should the nurse take first?
- A. Check with the case manager on duty about possible police intervention.
- B. Provide an environment of concern and emotional stabilization.
- C. Clean the patient's wounds with normal saline and gauze.
- D. Refer the patient to a counselor specializing in trauma.
Correct answer: B
Rationale: In a situation where a patient describes a brutal assault and rape, the first priority should be to provide emotional support and create a safe and supportive environment. This helps the patient feel secure and cared for, which is crucial for their well-being at that moment. Checking with the case manager about police intervention should come after ensuring the patient's immediate emotional needs are addressed. Cleaning the patient's wounds, though important, can be secondary to providing emotional stabilization. Referring the patient to a counselor specializing in trauma is also crucial for long-term support, but the immediate focus should be on providing emotional support and stability.
3. A nurse is weighing a breastfed 6-month-old infant who has been brought to the pediatrician's office for a scheduled visit. The infant's weight at birth was 6 lb 8 oz. The nurse notes that the infant now weighs 13 lb. What action should the nurse take?
- A. Tell the mother to decrease the daily number of feedings because the weight gain is excessive.
- B. Tell the mother that the infant's weight is increasing as expected.
- C. Tell the mother that the infant should continue with breast milk as the weight gain is adequate.
- D. Tell the mother that semisolid foods should not be introduced until the infant's weight stabilizes.
Correct answer: B
Rationale: The correct answer is to inform the mother that the infant's weight gain is normal. Infants typically double their birth weight by 6 months, which is precisely the case here, with the infant's weight increasing from 6 lb 8 oz to 13 lb. This weight gain indicates healthy growth and development. Therefore, there is no need to decrease feedings. The infant should continue with breast milk as it is providing adequate nutrition. Additionally, introducing semisolid foods is usually recommended between 4 and 6 months of age, so there is no indication to delay based on the infant's weight gain.
4. Ten-year-old Jackie is admitted to the hospital with a medical diagnosis of Rheumatic Fever. She relates a history of 'a sore throat about a month ago.' Bed rest with bathroom privileges is prescribed. Which of the following nursing assessments should be given the highest priority when assessing Jackie's condition?
- A. her response to hospitalization
- B. the presence of a macular rash on her trunk
- C. her cardiac status
- D. the presence of polyarthritis and joint pain
Correct answer: C
Rationale: Monitoring Jackie's cardiac status is of the highest priority in a patient with rheumatic fever. Rheumatic fever can lead to permanent cardiac damage, making it crucial to closely monitor the heart. Assessing for signs of carditis, such as murmurs or other cardiac symptoms, is essential. The second priority is evaluating joint symptoms for the presence of polyarthritis and pain, which are common manifestations of rheumatic fever. While assessing Jackie's response to hospitalization is important for her emotional well-being, it is not the highest priority. The presence of a macular rash, although relevant, is not as high a priority as monitoring cardiac status or assessing joint symptoms.
5. When encountering the significant other of a patient with end-stage AIDS crying during her smoke break, what is the most appropriate action for the nurse to take?
- A. Allow her to grieve by herself.
- B. Tell her to go ahead and cry, after all, your husband’s pretty bad off.
- C. Tell her you realize how upset she is, but you don’t want to talk about it now.
- D. Approach her, offering tissues, and encourage her to verbalize her feelings
Correct answer: D
Rationale: Approaching the significant other, offering tissues, and encouraging her to verbalize her feelings is the most appropriate action for the nurse to take. Being left alone during the grief process isolates individuals, and they need an outlet for their feelings. By showing empathy and providing support, the nurse can help the significant other cope with her emotions. Choices A, B, and C are inappropriate because they do not offer support or encourage the expression of feelings, which are crucial in such situations.
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