NCLEX-PN
NCLEX PN Exam Cram
1. A 14-year-old boy has been admitted to a mental health unit for observation and treatment. The boy becomes agitated and starts yelling at nursing staff members. What should the nurse's first response be?
- A. Create an atmosphere of seclusion for the boy according to procedures.
- B. Remove other patients from the area for added safety.
- C. Ask the patient, "What is making you mad?"?
- D. Ask the patient, "Why are you behaving this way? Have you thought about what may help you calm down?"?
Correct answer: A
Rationale: In a situation where a patient is agitated and yelling, the first response should be to create an atmosphere of seclusion for the safety of the patient and others. Seclusion is a standard procedure to help manage aggressive behaviors and prevent harm. Options B, C, and D are not appropriate in this scenario. Removing other patients may not address the immediate safety concern, asking the patient what is making them mad can escalate the situation, and questioning why the patient is behaving that way may not help in managing the current agitation. Therefore, seclusion is the recommended course of action in this scenario to ensure the safety and well-being of all involved.
2. Which system is primarily affected by tuberculosis (Mycobacterium)?
- A. stomach (GI)
- B. heart (cardiac)
- C. lungs (respiratory)
- D. skin (integumentary)
Correct answer: C
Rationale: Tuberculosis, caused by Mycobacterium tuberculosis, primarily affects the respiratory system. This aerobic bacillus thrives in highly oxygenated body sites, such as the lungs, growing ends of bones, and the brain. The bacillus is airborne, making the lungs a common site for infection. Choices A, B, and D are incorrect as tuberculosis predominantly impacts the respiratory system and rarely involves the stomach, heart, or skin.
3. A 15-year-old high school wrestler has been taking diuretics to lose weight to compete in a lower weight class. Which of the following medical tests is most likely to be given?
- A. Lab values of Potassium and Sodium
- B. Lab values of Glucose and Hemoglobin
- C. ECG
- D. CT scan
Correct answer: A
Rationale: Diuretics can disrupt the sodium and potassium balance, potentially leading to cardiac complications. Monitoring the lab values of potassium and sodium is crucial to assess electrolyte imbalances due to diuretic use. Testing glucose and hemoglobin levels is not directly related to diuretic use in this context. An ECG would be indicated if there were signs or symptoms of cardiac abnormalities, but it is not the primary test to monitor the effects of diuretics. A CT scan is not typically used to assess electrolyte imbalances caused by diuretics.
4. Which of the following should not be included in the teaching for clients who take oral iron preparations?
- A. Mix the liquid iron preparation with antacids to reduce GI distress.
- B. Take the iron with meals if GI distress occurs.
- C. Liquid forms should be taken with a straw to avoid discoloration of tooth enamel.
- D. Oral forms should be taken with juice, not milk.
Correct answer: A
Rationale: The correct answer is to mix the liquid iron preparation with antacids to reduce GI distress. This statement is incorrect because iron should not be mixed with antacids as it can significantly reduce the absorption of iron. Choice B is a good recommendation as taking iron with meals can help reduce gastrointestinal distress. Choice C is also correct as liquid forms of iron should be taken with a straw to prevent the discoloration of tooth enamel. Choice D is incorrect as iron preparations can be taken with juice or water, but not with milk, as calcium in milk can inhibit iron absorption.
5. 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.
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