NCLEX-PN
NCLEX PN Exam Cram
1. A 27-year-old woman has delivered twins in the OB unit. The patient develops a condition of 5-centimeter diastasis recti abdominis. Which of the following statements is the most accurate when instructing the patient?
- A. Avoid sit-ups to prevent worsening the condition.
- B. Surgery is not always necessary for this condition.
- C. Guarding the abdominal region is important at this time.
- D. Antibiotics are not needed for diastasis recti abdominis.
Correct answer: C
Rationale: After experiencing diastasis recti abdominis, it is crucial for the patient to protect and guard the abdominal region to facilitate healing. Choice A is correct since avoiding sit-ups is important to prevent worsening the condition by increasing intra-abdominal pressure. Choice B is accurate as not all cases of diastasis recti abdominis require surgery; conservative management is often effective. Choice D is also correct as antibiotics are not indicated for diastasis recti abdominis since it is a separation of the abdominal muscles and not an infectious condition.
2. The healthcare provider should utilize data about which of the following to provide information about the nutritional status of a client being evaluated for malnutrition?
- A. triceps skinfold measurement
- B. fasting blood glucose level
- C. hemoglobin A1c level
- D. serum lipid profile results
Correct answer: A
Rationale: Objective anthropometric measurements such as triceps skinfold and mid-arm circumference (MAC), along with weight, are usually used to diagnose malnutrition. Triceps skinfold measurement specifically helps assess body fat and muscle mass, providing valuable information about the client's nutritional status. Fasting blood glucose level, hemoglobin A1c level, and serum lipid profile results are important tests in assessing different aspects of health such as diabetes management and cardiovascular risk, but they are not specific indicators of malnutrition.
3. Which dietary consideration is most important for the nurse to teach to a client with hypothyroidism?
- A. Increase carbohydrate intake
- B. Increase fluid intake
- C. Avoid shellfish
- D. Increase fiber
Correct answer: D
Rationale: The correct answer is to 'Increase fiber.' In hypothyroidism, clients often experience constipation due to decreased metabolic rate. Increasing fiber in the diet can help alleviate constipation. Choice A, 'Increase carbohydrate intake,' is incorrect as there is no specific need to increase carbohydrate intake in hypothyroidism. Choice B, 'Increase fluid intake,' is not directly related to managing hypothyroidism, although adequate hydration is generally important for overall health. Choice C, 'Avoid shellfish,' is commonly associated with hyperthyroidism due to its iodine content, not hypothyroidism.
4. The nurse observes a nursing assistant performing AM care for a client with a new leg cast. Which action by the assistant will the nurse intervene?
- A. Lifting the affected leg with the palms of the hand
- B. Covering the affected leg with a blanket to avoid chills
- C. Placing plastic over the groin prior to bathing
- D. Elevating the cased leg on two pillows
Correct answer: B
Rationale: The correct answer is covering the affected leg with a blanket to avoid chills. Covering the leg with a blanket can prevent the evaporation of heat from the new cast, which can lead to skin irritation or discomfort. Lifting the affected leg with the palms of the hand is appropriate as it helps in providing support and prevents unnecessary pressure on the cast. Placing plastic over the groin prior to bathing is also acceptable to protect the area from getting wet. Elevating the cased leg on two pillows helps reduce swelling and promotes circulation, making it a suitable action.
5. A 32-year-old male with a complaint of dizziness has an order for Morphine via IV. What should the nurse do first?
- A. Check the patient's chest x-ray results.
- B. Retake vitals including blood pressure.
- C. Perform a neurological screening on the patient.
- D. Request the physician on-call to assess the patient.
Correct answer: B
Rationale: The correct first action for the nurse to take in this situation is to retake the patient's vitals, including blood pressure. Dizziness can be a sign of hypotension, which may be a contraindication for administering Morphine. Checking the chest x-ray results (Choice A) would not be the priority in this case as addressing the dizziness is more urgent. Performing a neurological screening (Choice C) may be important but not the first step when a patient presents with dizziness and an order for Morphine. Requesting the physician to assess the patient (Choice D) should come after the initial assessment and vitals retake.
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