NCLEX-PN
NCLEX PN Exam Cram
1. The client in the Emergency Department, who has suffered an ankle sprain, should be taught to:
- A. use cold applications to the sprain during the first 24-48 hours.
- B. expect disability to decrease within the first 24 hours of injury
- C. expect pain to decrease within 3 hours after injury.
- D. begin progressive passive and active range of motion exercises immediately.
Correct answer: A
Rationale: When a client suffers an ankle sprain, the nurse should teach them to use cold applications to the sprain during the first 24-48 hours. Cold applications are believed to produce vasoconstriction and reduce the development of edema. Expecting disability to decrease within the first 24 hours of injury (choice B) is incorrect as disability and pain are anticipated to increase during the first 2-3 hours after injury. Expecting pain to decrease within 3 hours after injury (choice C) is also incorrect as pain and swelling usually increase initially. Beginning progressive passive and active range of motion exercises immediately (choice D) is not recommended; these exercises are usually started 2-5 days after the injury, according to the physician's recommendation. Treatment for a sprain involves support, rest, and alternating cold and heat applications. X-ray pictures are often necessary to rule out any fractures.
2. Which hormone is responsible for amenorrhea in the pregnant woman?
- A. Progesterone
- B. Estrogen
- C. Follicle-stimulating hormone (FSH)
- D. Human chorionic gonadotropin (hCG)
Correct answer: A
Rationale: Correct! Progesterone is the hormone responsible for amenorrhea in pregnant women. Progesterone plays a crucial role in maintaining the uterine lining for implantation and supporting early pregnancy. High levels of progesterone during pregnancy suppress the normal menstrual cycle, leading to amenorrhea. Estrogen, FSH, and hCG do not directly cause amenorrhea in pregnant women. Estrogen is involved in the development of female secondary sexual characteristics, FSH is involved in the growth and maturation of ovarian follicles, and hCG is produced by the placenta to support the production of progesterone during pregnancy.
3. 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.
4. Which action by a graduate nurse would require the charge nurse to intervene?
- A. Walking in the hallway outside the operating room without a hair covering
- B. Putting on a surgical mask, gown, and cap before entering the operating room
- C. Wearing a surgical mask into the holding area
- D. Wearing scrubs from home into the nursing station
Correct answer: A
Rationale: The correct answer is walking in the hallway outside the operating room without a hair covering. In healthcare settings, it is crucial to adhere to infection control measures, which include wearing appropriate attire to prevent the spread of pathogens. Walking in the hallway outside the operating room without a hair covering violates these infection control protocols, necessitating immediate intervention by the charge nurse. Choices B and C are incorrect because putting on surgical attire before entering the operating room and wearing a surgical mask into the holding area are both standard practices that promote patient safety and infection control. Choice D is also incorrect as wearing scrubs from home into the nursing station, while not ideal, is not a violation that warrants immediate intervention compared to breaching infection control protocols near sensitive areas like the operating room.
5. 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.
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