NCLEX-PN
Quizlet NCLEX PN 2023
1. A 64-year-old Alzheimer's patient has exhibited excessive cognitive decline resulting in harmful behaviors. The physician orders restraints to be placed on the patient. Which of the following is the appropriate procedure?
- A. Secure the restraints to the bed rails on all extremities.
- B. Notify the physician that restraints have been placed properly.
- C. Communicate with the patient and family the need for restraints.
- D. Position the head of the bed at a 45-degree angle.
Correct answer: C
Rationale: In cases where restraints are considered necessary for a patient, it is crucial to communicate effectively with both the patient and their family about the reasons for this decision. This helps ensure that all parties involved understand the necessity of restraints and are informed about the potential risks and benefits. Option A, securing restraints to the bed rails on all extremities, is not appropriate as it does not involve proper communication or ethical considerations. Option B, notifying the physician that restraints have been placed properly, overlooks the importance of patient and family involvement in decision-making. Option D, positioning the head of the bed at a 45-degree angle, is unrelated to the use of restraints and does not address the situation at hand.
2. A nurse is caring for a patient in the step-down unit. The patient has signs of increased intracranial pressure. Which of the following is not a sign of increased intracranial pressure?
- A. Bradycardia
- B. Increased pupil size bilaterally
- C. Change in LOC
- D. Vomiting
Correct answer: B
Rationale: The correct answer is 'Increased pupil size bilaterally.' When assessing for signs of increased intracranial pressure, bilateral pupil dilation is not typically associated with this condition. Instead, unilateral pupil changes, especially one pupil becoming dilated or non-reactive while the other remains normal, are indicative of increased ICP. Bradycardia, a change in level of consciousness (LOC), and vomiting are commonly seen in patients with increased intracranial pressure due to the brain's response to the rising pressure. Therefore, the presence of bilateral pupil dilation goes against the typical pattern observed in patients with increased intracranial pressure.
3. A client with sickle cell disease is worried about passing the disease on to children. Which of the following statements by the PN is most appropriate for this client?
- A. "You should discuss the inheritance risk with your physician."?
- B. "Sickle cell disease is genetically based and might be passed on to children."?
- C. "Sickle cell disease is genetically based and is not passed on to children."?
- D. "Sickle cell disease is caused by an infection and cannot be passed on to children."?
Correct answer: B
Rationale: A client with sickle cell disease has a genetic condition that can be passed on to their offspring. The most appropriate statement for the PN to provide is to acknowledge this fact and inform the client that sickle cell disease is genetically based and might be passed on to children. This empowers the client with accurate information. Choice A has been refined to emphasize discussing the inheritance risk, making it a better option than the vague original choice. Choices C and D provide incorrect information. Sickle cell disease is indeed genetically based and can be inherited.
4. What is the next step for a 64-year-old male diagnosed with COPD and CHF who shows a 10 lbs increase in total body weight over the last few days?
- A. Contact the patient's physician immediately.
- B. Check the intake and output on the patient's flow sheet.
- C. Encourage the patient to ambulate to reduce lower extremity edema.
- D. Check the patient's vitals every 2 hours.
Correct answer: B
Rationale: In a patient with COPD and CHF experiencing a sudden increase in total body weight, the priority is to check the intake and output on the patient's flow sheet to evaluate fluid balance. This assessment helps determine if the weight gain is due to fluid retention, which can exacerbate CHF. Contacting the physician may be necessary based on the intake and output findings. While encouraging ambulation is beneficial for circulation, it may not address the root cause of fluid retention. Checking vitals every 2 hours is important for monitoring stability but may not pinpoint the reason behind the weight gain.
5. A mother of a newborn notices a nurse placing liquid in her baby's eyes. Which of the following is an inaccurate statement about the need for eyedrops following birth?
- A. Eyedrops following birth help reduce the risk of eye infection.
- B. Eyedrops are required by law.
- C. Eyedrops will keep the eye moist.
- D. Eyedrops are required by law every 6 hours following birth.
Correct answer: D
Rationale: The correct answer is 'Eyedrops are required by law every 6 hours following birth.' This statement is inaccurate because while laws do require the placement of eyedrops, physicians indicate a specific timeframe for their administration. Choice A is correct because eyedrops following birth do help reduce the risk of eye infection by preventing ophthalmia neonatorum. Choice B is incorrect as it implies that eyedrops are mandated solely by law, without considering medical reasons. Choice C is accurate as eyedrops do help keep the eye moist, preventing dryness and discomfort.
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