NCLEX-PN
NCLEX-PN Quizlet 2023
1. Why must the nurse be careful not to cut through or disrupt any tears, holes, bloodstains, or dirt present on the clothing of a client who has experienced trauma?
- A. The clothing is the property of another and must be treated with care.
- B. Such care facilitates repair and salvage of the clothing.
- C. The clothing of a trauma victim is potential evidence with legal implications.
- D. Such care decreases trauma to the family members receiving the clothing.
Correct answer: C
Rationale: The correct answer is C. Trauma in any client, living or dead, has potential legal and/or forensic implications. Clothing, patterns of stains, and debris are sources of potential evidence and must be preserved. Nurses must be aware of state and local regulations that require mandatory reporting of cases of suspected child and elder abuse, accidental death, and suicide. Each Emergency Department has written policies and procedures to assist nurses and other health care providers in making appropriate reports. Physical evidence is real, tangible, or latent matter that can be visualized, measured, or analyzed. Emergency Department nurses can be called on to collect evidence. Health care facilities have policies governing the collection of forensic evidence. The chain of evidence custody must be followed to ensure the integrity and credibility of the evidence. The chain of evidence custody is the pathway that evidence follows from the time it is collected until it has served its purpose in the legal investigation of an incident. Choices A, B, and D are incorrect because they do not address the crucial aspect of preserving potential evidence with legal implications that may be present on the clothing of a trauma victim.
2. A nurse working in a pediatric clinic observes the following situations. Which of the following may indicate a delayed child to the nurse?
- A. A 12-month-old that does not 'cruise'.
- B. An 8-month-old that can sit upright unsupported.
- C. A 6-month-old that is rolling prone to supine.
- D. A 3-month-old that does not roll supine to prone.
Correct answer: A
Rationale: The correct answer is 'A 12-month-old that does not 'cruise''. At 12 months, a child should at least be 'cruising' (holding on to objects to walk), which is considered pre-walking. The other choices describe age-appropriate developmental milestones: sitting upright unsupported by 8 months, rolling prone to supine by 6 months, and rolling supine to prone by 3 months. Not 'cruising' at 12 months may indicate a delay in motor skills development.
3. A healthcare professional is reviewing a patient's current Lithium levels. Which of the following values is outside the therapeutic range?
- A. 1.0 mEq/L
- B. 1.1 mEq/L
- C. 1.2 mEq/L
- D. 1.3 mEq/L
Correct answer: D
Rationale: The correct answer is 1.3 mEq/L. The therapeutic range for Lithium levels typically falls between 0.6 to 1.2 mEq/L. Values below or above this range can lead to suboptimal treatment outcomes or toxicity. Choices A, B, and C are within the therapeutic range of 1.0-1.2 mEq/L, making them appropriate levels for patient care.
4. A nurse suspects a patient is developing Bell's Palsy. The nurse wants to test the function of cranial nerve VII. Which of the following would be the most appropriate testing procedures?
- A. Test the taste sensation over the back of the tongue and activation of the facial muscles.
- B. Test the taste sensation over the front of the tongue and activation of the facial muscles.
- C. Test the sensation of the facial muscles and sensation of the back of the tongue.
- D. Test the sensation of the facial muscles and sensation of the front of the tongue.
Correct answer: B
Rationale: The facial nerve (VII) is responsible for motor function to the face and sensory function to the anterior two-thirds of the tongue. Therefore, to appropriately test the function of cranial nerve VII, the most appropriate testing procedures involve assessing the taste sensation over the front of the tongue (sensory) and activation of the facial muscles (motor). Option B, 'Test the taste sensation over the front of the tongue and activation of the facial muscles,' is the correct answer. Choices A, C, and D are incorrect because they do not involve the correct combination of sensory testing over the front of the tongue and motor activation of the facial muscles, which are key functions associated with cranial nerve VII.
5. A client has been taking a drug (Drug A) that is highly metabolized by the cytochrome P-450 system. He has been on this medication for 6 months. At this time, he is started on a second medication (Drug B) that is an inducer of the cytochrome P-450 system. You should monitor this client for:
- A. increased therapeutic effects of Drug A.
- B. increased adverse effects of Drug B.
- C. decreased therapeutic effects of Drug A.
- D. decreased therapeutic effects of Drug B.
Correct answer: C
Rationale: When a client is taking a drug (Drug A) metabolized by the cytochrome P-450 system and is then started on another drug (Drug B) that induces this system, the metabolism of Drug A is increased. This results in decreased therapeutic effects of Drug A as it is broken down more rapidly. Monitoring is required to address potential reduced efficacy. The therapeutic effect of Drug A is diminished, not enhanced. Inducing the cytochrome P-450 system does not directly increase the adverse effects of Drug B. Although Drug B is an inducer, its therapeutic effects are not decreased as it is not metabolized faster.
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