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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?

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. The PN is caring for a client with diabetes insipidus. The nurse can expect the lab work to show:

Correct answer: D

Rationale: In diabetes insipidus, the pituitary releases too much antidiuretic hormone (ADH), causing the client to produce a large amount of dilute urine (decreased osmolarity) and leading to dehydration (elevated serum osmolarity). Therefore, the correct answer is decreased urine osmolarity and elevated serum osmolarity. Choice C, elevated urine osmolarity and decreased serum osmolarity, is incorrect for diabetes insipidus, as it is more characteristic of syndrome of inappropriate ADH (SIADH). Choices A and B, elevated urine osmolarity and elevated serum osmolarity, and decreased urine osmolarity and decreased serum osmolarity, respectively, are generally not seen in diabetes insipidus, as urine and serum osmolarity typically move in opposite directions in this condition.

3. A patient has suffered a left CVA and developed severe hemiparesis resulting in a loss of mobility. The nurse notices on assessment that an area over the patient's left elbow appears as non-blanchable erythema, and the skin is intact. The nurse should score the patient as having which of the following?

Correct answer: A

Rationale: Erythema with the skin intact is characteristic of a Stage I pressure ulcer. At this stage, the skin is not broken, but there is localized redness that does not blanch when pressed. Stage II pressure ulcers involve partial-thickness skin loss, Stage III pressure ulcers have full-thickness skin loss, and Stage IV pressure ulcers extend to deeper tissues, including muscle and bone. In this case, the non-blanchable erythema with intact skin aligns with the characteristics of a Stage I pressure ulcer.

4. When teaching a patient with COPD pulmonary exercises, what should be done?

Correct answer: A

Rationale: The correct answer is to teach pursed-lip breathing techniques. Pursed-lip breathing helps to decrease the volume of air expelled by keeping the airways open longer, making it easier for patients with COPD to breathe out. Encouraging heavy lifting exercises (Choice B) is not suitable for patients with COPD as it can lead to increased shortness of breath. Limiting exercises due to respiratory acidosis (Choice C) is not correct; instead, exercises should be tailored to the patient's tolerance. Taking breaks every 10-20 minutes (Choice D) is not specific to the management of COPD pulmonary exercises.

5. Which of the following lab values would indicate symptomatic AIDS in the medical chart? (T4 cell count per deciliter)

Correct answer: D

Rationale: A T4 cell count of less than 200 cells per deciliter indicates symptomatic AIDS. This severe depletion of T4 cells signifies advanced HIV infection and a significantly compromised immune system. Choices A, B, and C are incorrect because T4 cell counts above 2000, above 1000, or below 500 cells per deciliter, respectively, are not indicative of symptomatic AIDS.

Similar Questions

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?
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