NCLEX-PN
NCLEX PN Exam Cram
1. Which type of cells secrete insulin?
- A. alpha cells
- B. beta cells
- C. CD4 cells
- D. helper cells
Correct answer: B
Rationale: Beta cells are responsible for secreting insulin. Insulin is produced by beta cells in the pancreas and plays a crucial role in regulating blood sugar levels. Alpha cells secrete glucagon, not insulin (Choice A). CD4 cells are a type of immune cell that helps coordinate the immune response (Choice C). Helper cells are a type of immune cell that aids in activating other immune cells (Choice D). Therefore, the correct answer is beta cells.
2. The nurse is caring for a client who is 28 weeks pregnant and complains of swollen hands and feet. Which symptom below would cause the greatest concern?
- A. Nasal congestion
- B. Hiccups
- C. Blood glucose of 150
- D. Muscle spasms
Correct answer: D
Rationale: The correct answer is muscle spasms because they can be indicative of a severe condition like preeclampsia, which is a serious complication during pregnancy characterized by high blood pressure and signs of damage to another organ system, most often the liver and kidneys. Nasal congestion and hiccups are common discomforts during pregnancy and do not pose a severe risk to the client or fetus. A blood glucose level of 150, while slightly elevated, may not be alarming in a pregnant individual and can be managed through dietary modifications or medication adjustments. Muscle spasms, especially in the context of pregnancy, should be taken seriously and thoroughly assessed to rule out any underlying serious conditions.
3. A 13-year-old girl is admitted to the ER with lower right abdominal discomfort. What should the admitting nurse do first?
- A. Administer Loritab to the patient for pain relief.
- B. Place the patient in a right sidelying position for pressure relief.
- C. Start a Central Line.
- D. Provide pain reduction techniques without administering medication.
Correct answer: D
Rationale: In a case of lower right abdominal discomfort, the first step should be to provide pain reduction techniques without administering medication. Administering pain medication or starting a central line should not be done without medical orders. Placing the patient in a right sidelying position may help with pressure relief, but addressing pain reduction techniques without medication is the initial priority in this scenario. It is essential to assess the patient further, consult with a healthcare provider, and follow the appropriate protocols before administering any medication or invasive procedures like starting a central line.
4. After administering enoxaparin (Lovenox) subcutaneously into the abdomen, which action should the nurse take?
- A. Gently rub the injection site after removing the needle
- B. Have the client maintain a side-lying position for at least five minutes
- C. Remove the needle and engage the needle safety device
- D. Apply heat to the injection site
Correct answer: C
Rationale: After administering a subcutaneous injection of enoxaparin (Lovenox) into the abdomen, the nurse should remove the needle and engage the needle safety device. Rubbing the injection site after the needle is withdrawn is not recommended as it may cause irritation and bruising. Having the client maintain a side-lying position for at least five minutes is unnecessary for a subcutaneous injection into the abdomen. Applying heat to the injection site is not indicated after administering enoxaparin subcutaneously; it could increase the risk of bleeding or bruising at the injection site.
5. 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.
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