a nurse is participating in a planning conference to improve dietary measures for an older client who is experiencing dysphagia which action should th
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Nursing Elites

NCLEX-PN

2024 PN NCLEX Questions

1. A nurse is participating in a planning conference to improve dietary measures for an older client experiencing dysphagia. Which action should the nurse suggest including in the plan of care?

Correct answer: A

Rationale: For clients with dysphagia, ensuring successful swallowing of food and preventing aspiration is crucial. Therefore, the nurse should suggest monitoring the client closely during meals to provide assistance as needed. While a balanced diet is important, special considerations like adding thickeners for liquids may be required for dysphagia clients. Consulting with a physician about enteral tube feeding should be based on the severity of the condition, making it a premature step without clear indications. Encouraging self-feeding may not be appropriate for dysphagia clients who require close monitoring and assistance, as it could increase the risk of complications.

2. A nurse assisting with data collection of a client gathers both subjective and objective data. Which finding would the nurse document as subjective data?

Correct answer: C

Rationale: Subjective data are information provided by the client about their symptoms, feelings, or experiences. In this case, the client reporting having a rash is subjective data because it is based on what the client says. Choices A, B, and D involve observations or measurements made by the nurse (anxious appearance, blood pressure, reflexes), which fall under objective data. Objective data are observable and measurable data obtained through physical examination, vital signs assessment, and laboratory tests.

3. A nurse calculates a newborn infant's Apgar score 1 minute after birth and determines that the score is 6. What is the most appropriate action for the nurse to take?

Correct answer: B

Rationale: The Apgar score is a method for rapidly evaluating an infant's cardiorespiratory adaptation after birth. The nurse assigns scores in five areas: heart rate, respiratory effort, muscle tone, reflex response, and color, totaling the scores. A score of 8 to 10 requires no action other than supporting the infant's spontaneous efforts and observation. A score of 4 to 7 indicates the need to gently stimulate the infant by rubbing his back while administering oxygen. If the score is 1 to 3, the infant requires resuscitation. Therefore, in this scenario with an Apgar score of 6, the correct action is to gently stimulate the infant by rubbing his back while administering oxygen. Initiating cardiopulmonary resuscitation would be excessive at this point, and rechecking the score in 5 minutes may delay necessary interventions. Providing no action except to support the infant's spontaneous efforts is insufficient for a score of 6, indicating the need for stimulation and oxygen administration.

4. When a client who is having trouble conceiving says to the nurse, 'I have started taking ginseng,' the best response by the nurse is:

Correct answer: B

Rationale: Some studies have shown that ginseng enhances in vitro sperm motility, making Choice B the correct response. It directly addresses the client's comments about taking ginseng and provides valuable information regarding its potential effect on sperm motility. Alternative therapies are often sought by couples struggling with infertility, and acknowledging the potential benefits of ginseng can empower the client. Choice A is incorrect as it slightly misrepresents the evidence by overgeneralizing its effectiveness. Choice C dismisses ginseng without acknowledging its potential benefits, potentially closing off a fruitful discussion with the client. Choice D, while neutral, misses the opportunity to validate the client's choice and explore further options collaboratively. It is crucial for nurses to respect clients' choices, provide accurate information, and guide them effectively in exploring different alternatives.

5. During a throat assessment, a healthcare provider asks a client to stick out their tongue and notices it protrudes in the midline. Which cranial nerve is being tested?

Correct answer: D

Rationale: The correct answer is cranial nerve XII (hypoglossal nerve). When testing cranial nerve XII, the healthcare provider inspects the symmetry and movement of the tongue. The tongue should protrude in the midline when the client sticks it out. Cranial nerve IX (glossopharyngeal nerve) and X (vagus nerve) are tested by depressing the tongue with a blade to observe pharyngeal movement and gag reflex. Cranial nerve V (trigeminal nerve) is responsible for testing the muscles of mastication, not tongue protrusion.

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