NCLEX-PN
NCLEX PN Exam Cram
1. When placing an IV line in a patient with active TB and HIV, which safety equipment should the nurse wear?
- A. Sterile gloves, mask, and goggles
- B. Surgical cap, gloves, mask, and proper shoewear
- C. Double gloves, gown, and mask
- D. Goggles, mask, gloves, and gown
Correct answer: D
Rationale: When dealing with a patient with active TB and HIV, the nurse should wear goggles, a mask, gloves, and a gown to protect themselves from potential exposure to infectious agents through respiratory secretions or blood. Surgical cap and proper shoewear are not specifically required for this procedure, making option B incorrect. Double gloving is not necessary in this scenario, hence option C is incorrect. Therefore, the correct choice is D as it includes all the essential protective equipment for this situation.
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. What is the best nursing diagnosis for a client with newly diagnosed Diabetes Mellitus?
- A. Impaired Skin Integrity
- B. Knowledge Deficit: New Diabetes Diagnosis
- C. Alteration in Nutrition: More than Body Requirements
- D. Fluid Volume Deficit
Correct answer: B
Rationale: The correct answer is 'Knowledge Deficit: New Diabetes Diagnosis.' Newly diagnosed diabetics require education on their disease, medications, glucose testing, insulin injections, foot care, and sick-day plans. Choices A and D aim to prevent issues that do not currently exist for the client. Choice C, 'Alteration in Nutrition: More than Body Requirements,' is not the priority diagnosis for a newly diagnosed diabetic. While nutritional adjustments may be required for type I or type II diabetes, providing knowledge and education takes precedence at this stage.
4. After experiencing a left frontal lobe CVA, a fifty-five-year-old man is being monitored by a nurse. The patient's family is not present in the room. What should the nurse observe most closely for?
- A. Changes in emotion and behavior
- B. Monitor loss of hearing
- C. Observe appetite and vision deficits
- D. Changes in facial muscle control
Correct answer: A
Rationale: The correct answer is to watch for changes in emotion and behavior. The frontal lobe, particularly the left side, is responsible for regulating behavior and emotions. Therefore, following a left frontal lobe CVA, monitoring for alterations in emotion and behavior is crucial. Choices B, C, and D are incorrect because loss of hearing, appetite and vision deficits, and changes in facial muscle control are not directly associated with a left frontal lobe CVA.
5. When giving an intramuscular injection to an infant, which of the following sites is preferred?
- A. Ventrogluteal region
- B. Deltoid
- C. Vastus lateralis
- D. Dorsogluteal region
Correct answer: C
Rationale: The correct answer is the Vastus lateralis when giving an intramuscular injection to an infant. The Vastus lateralis muscle, located in the thigh, is the preferred site for infants as it has a larger muscle mass and is well-developed, making it suitable for injections. The Ventrogluteal region and Dorsogluteal region are not recommended for infants due to their smaller muscle mass and potential risk of damaging nearby structures. The Deltoid muscle is typically used for older children and adults, not infants.
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