NCLEX-PN
NCLEX PN Exam Cram
1. A central venous pressure reading of 11cm/H(2)O of an IV of normal saline is determined by the nurse caring for the patient. The patient has a diagnosis of pericarditis. Which of the following is the most applicable?
- A. The patient has a condition of hypovolemia.
- B. Not enough fluid has been given to the patient.
- C. Pericarditis may cause pressures greater than 10cm/H(2)O with testing of CVP.
- D. The patient may have a condition of arteriosclerosis.
Correct answer: C
Rationale: A central venous pressure reading above 10cm/H(2)O may indicate a condition of pericarditis, as the inflammation and fluid accumulation around the heart can lead to elevated pressures. Choices A, B, and D are incorrect. Hypovolemia would typically result in lower CVP readings, not higher. Not enough fluid given would also lead to lower CVP levels. Arteriosclerosis is not directly related to CVP readings in the context of pericarditis.
2. 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.
3. A client who has a known history of cardiac problems and is still smoking enters the clinic complaining of sudden onset of sharp, stabbing pain that intensifies with a deep breath. The pain is occurring on only one side and can be isolated upon general assessment. The nurse concludes that this description is most likely caused by:
- A. pleurisy.
- B. pleural effusion.
- C. atelectasis.
- D. tuberculosis.
Correct answer: A
Rationale: Pleurisy is an inflammation of the pleura and is often accompanied by an abrupt onset of pain. Symptoms of pleurisy include sudden sharp, stabbing pain that is usually unilateral and localized to a specific portion of the chest. The pain can be exacerbated by deep breathing. In contrast, pleural effusion is characterized by fluid accumulation in the pleural space, not sharp pain. Atelectasis involves collapse or closure of a lung leading to reduced gas exchange, but it does not typically present with sharp, stabbing pain. Tuberculosis is a bacterial infection that can affect the lungs but does not typically manifest with sudden sharp pain exacerbated by deep breathing.
4. A healthcare provider is caring for a patient who has experienced burns to the right lower extremity. According to the Rule of Nines, which of the following percentages most accurately describes the severity of the injury?
- A. 36%
- B. 27%
- C. 18%
- D. 9%
Correct answer: C
Rationale: According to the Rule of Nines, the right lower extremity accounts for 18% of the total body surface area. The Rule of Nines divides the body into regions, each representing 9% or a multiple of 9%, allowing for a quick estimation of the extent of burns. In this case, the correct answer is 18% as it corresponds to the percentage allocated for each lower extremity. Choices A, B, and D are incorrect as they do not match the standard allocation for the right lower extremity in the Rule of Nines.
5. A 22-year-old patient in a mental health lock-down unit under suicide watch appears happy about being discharged. Which of the following is probably happening?
- A. The patient is excited about being around family again.
- B. The patient's suicide plan has probably progressed.
- C. The patient's plans for the future have been clarified.
- D. The patient's mood is improving.
Correct answer: B
Rationale: In this scenario, it is concerning that a patient under suicide watch is happy about being discharged as it may indicate that the patient's suicide plan has advanced. This change in behavior should be taken seriously as it can signal an increased risk of self-harm. Choices A, C, and D are less likely as the patient's happiness about discharge in this context is more indicative of a worsening situation rather than positive outcomes like being around family, clarifying future plans, or improving mood.
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