NCLEX-PN
Nclex 2024 Questions
1. A client has rectal cancer and is scheduled for an abdominal perineal resection. What should be the priority nursing care during the post-op period?
- A. Teaching perineal wound care techniques
- B. Monitoring electrolyte levels
- C. Encouraging early ambulation
- D. Facilitating perineal wound drainage
Correct answer: D
Rationale: The priority nursing care during the post-op period for a client who underwent an abdominal perineal resection is to facilitate perineal wound drainage. This is crucial for preventing infection of the surgical site and promoting healing. Teaching perineal wound care techniques, as in choice A, is more appropriate than ileostomy care in this scenario. While monitoring electrolyte levels is important, it is not the priority compared to ensuring proper wound drainage, making choice B less crucial. Encouraging early ambulation, as in choice C, is beneficial but not as critical as facilitating wound drainage immediately post-op.
2. A 57-year-old woman is recently widowed. She states, "I will never be able to learn how to manage the finances. My husband did all of that."? Select the nurse's response that could help raise the client's self-esteem.
- A. "You feel inadequate because you have never learned to balance a checkbook."?
- B. "You should have insisted your husband teach you about the finances."?
- C. "You are strong and will learn how to manage your finances after a while."?
- D. "I believe in your strength to learn how to manage your finances in time."?
Correct answer: C
Rationale: The nurse should aim to boost the client's self-esteem by providing positive reinforcement. By stating, "You are strong and will learn how to manage your finances after a while,"? the nurse acknowledges the client's strength and capability, encouraging her to believe in herself. Choice A is incorrect as it focuses on the client's inadequacy rather than empowering her. Choice B places unnecessary blame on the client for not taking action in the past. Choice D, though positive, slightly alters the nurse's original phrase, making choice C the most appropriate response to uplift the client's self-esteem.
3. Which information obtained from the mother of a child with cerebral palsy most likely correlates to the diagnosis?
- A. She was born at 42 weeks gestation.
- B. She had meningitis when she was 6 months old.
- C. She had physiologic jaundice after delivery.
- D. She has frequent sore throats.
Correct answer: B
Rationale: The diagnosis of meningitis at age 6 months correlates to a diagnosis of cerebral palsy. Cerebral palsy, a neurological disorder, is often associated with birth trauma or infections of the brain or spinal column. Answers A, C, and D are not related to the question. Gestational length (choice A) is not a direct risk factor for cerebral palsy. Physiologic jaundice (choice C) and frequent sore throats (choice D) are not typically associated with cerebral palsy.
4. The nurse is caring for a client with epilepsy who is being treated with carbamazepine (Tegretol). Which laboratory value might indicate a serious side effect of this drug?
- A. Uric acid of 5 mg/dL
- B. Hematocrit of 33%
- C. WBC 2,000 per cubic millimeter
- D. Platelets 150,000 per cubic millimeter
Correct answer: C
Rationale: Carbamazepine (Tegretol) can suppress the bone marrow, leading to a decrease in the white blood cell count. A laboratory value of WBC 2,000 per cubic millimeter indicates a serious side effect of the drug. Choices A and D are within normal limits, while choice B is at the lower limit of normal. Therefore, choices A, B, and D are incorrect.
5. The client is admitted with chronic obstructive pulmonary disease. Blood gases reveal pH 7.36, CO2 45, O2 84, HCO3 28. The nurse would assess the client to be in:
- A. Uncompensated acidosis
- B. Compensated alkalosis
- C. Compensated respiratory acidosis
- D. Uncompensated metabolic acidosis
Correct answer: C
Rationale: The client is experiencing compensated respiratory acidosis. The pH is within the normal range but is lower than 7.40, indicating acidity. The elevated CO2 level and low O2 level suggest respiratory involvement. The slightly elevated HCO3 level indicates a compensatory mechanism. In respiratory acidosis, the pH will be inversely related to the CO2 and bicarb levels, with elevated CO2 and HCO3 levels contributing to acidosis. Choices A, B, and D are incorrect because they do not align with the presented blood gas values and the compensatory response observed in this case.
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