a community health nurse is providing information to a group of older clients about measures to decrease the risk of contracting inuenza during peak u
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NCLEX-PN

2024 PN NCLEX Questions

1. A community health nurse is providing information to a group of older clients about measures to decrease the risk of contracting influenza during peak flu season. The nurse should provide which information?

Correct answer: C

Rationale: During peak influenza season, older clients should take measures to reduce the risk of contracting the flu. The most effective preventive measure is frequent hand hygiene and refraining from touching the face, as this reduces the transmission of the flu virus. While it is advisable to avoid crowds, the direct action of hand hygiene is more impactful. Doing errands early in the morning when crowds are smaller is a good suggestion to reduce exposure but does not address the direct transmission through hands. Drinking enough fluid daily is important for overall health but does not directly reduce the risk of contracting influenza.

2. You are caring for a 78-year-old woman who is wondering why she was diagnosed with glaucoma. Although she has several risk factors, which of these is not one of them?

Correct answer: D

Rationale: Age over 60 and Mexican-American heritage are recognized as risk factors for glaucoma. Elevated blood pressure is also a risk factor due to its potential to cause optic nerve damage. While 20/80 vision indicates poor eyesight, it is not a direct causal factor for glaucoma. Glaucoma is mainly associated with factors like age, ethnicity, and certain medical conditions, rather than a specific visual acuity measurement. Therefore, 20/80 vision is not a risk factor for glaucoma, making it the correct answer. The other choices, such as age, Mexican-American heritage, and elevated blood pressure, are established risk factors for developing glaucoma, as they are associated with an increased likelihood of the condition.

3. Following the change of shift report, when can or should the nurse's plan be altered or modified during the shift?

Correct answer: C

Rationale: The correct answer is 'when needs change.' It is crucial for the nurse to remain adaptable and adjust the plan promptly when the patient's needs or condition change. Choice A, 'halfway through the shift,' may not align with the timing of when needs actually change, making it less optimal for plan modifications. Choice B, 'at the end of the shift before the nurse reports off,' is too late to address evolving needs effectively. Choice D, 'after the top-priority tasks have been completed,' limits the nurse's ability to respond promptly to changing priorities, as needs may shift before all top-priority tasks are finished.

4. A client turns her ankle. She is diagnosed as having a Pulled Ligament. This should be documented as a:

Correct answer: B

Rationale: The term 'strain' is the correct choice. A strain refers to the excessive stretching of a muscle or tendon, which aligns with a pulled ligament diagnosis. A sprain, on the other hand, involves ligament injury due to twisting motions. 'Subluxation' indicates a partial dislocation of a joint, not a pulled ligament. 'Dislocation' refers to the complete displacement of bones in a joint, which is not the appropriate term for a pulled ligament.

5. The nurse is caring for a 4-year-old client. What is the most appropriate pain scale for the nurse to use during the assessment?

Correct answer: D

Rationale: The correct answer is the Wong-Baker Pain Scale. This scale is specifically designed for pediatric clients, including children as young as 3 years old, making it the most appropriate choice for a 4-year-old. It utilizes a simple visual scale with facial expressions that children can easily understand and use to express their pain levels. The FLACC and CRIES Pain Scales are also used for pediatric clients but are more focused on non-verbal cues and specific populations like infants or critically ill children. The McGill Pain Scale, on the other hand, is more complex and uses descriptive words, making it more suitable for adult clients who can better articulate their pain experiences.

Similar Questions

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An older client reports that she has been awakening during the night, awakes early in the morning and is unable to fall back to sleep, and feels sleepy during the daytime. Based on these reported data, what should the nurse do?
A teenage client is admitted to the hospital because of acetaminophen (Tylenol) overdose. Overdoses of acetaminophen can precipitate life-threatening abnormalities in which of the following organs?
A nurse is reviewing the findings of a physical examination documented in a client's record. Which piece of information does the nurse recognize as objective data?
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