a nurse is reviewing the medical notes of a client seen by the physician to determine whether the client is pregnant the nurse determines that pregnan
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Nursing Elites

NCLEX-PN

2024 PN NCLEX Questions

1. When reviewing a client's medical notes to confirm pregnancy, a nurse should look for which finding to determine that pregnancy is confirmed?

Correct answer: C

Rationale: To confirm pregnancy, the presence of palpable fetal movement is a positive indicator. Palpable fetal movement is a certain sign of pregnancy, known as a fetal movement felt by the examiner. Amenorrhea is a presumptive sign of pregnancy as it is reported by the woman but is not confirmatory. Thinning of the cervix (Hegar sign) is a probable sign of pregnancy, which is not confirmatory. A positive result on a home urine test for pregnancy is also a probable indicator. However, a positive pregnancy test result can sometimes yield false-positive results due to various factors like medication, recent pregnancy, or errors in reading.

2. During a report from an ER nurse about a client, the nurse identifies a statement that requires additional follow-up. Which of the following statements needs further clarification?

Correct answer: A

Rationale: The correct answer requires further follow-up as the nurse needs to know the duration and dosage of aspirin since it can impact the patient's bleeding risk. Choice B does not require immediate follow-up as not taking antacids for three days is not critical. Choice C indicates a necessary decision made by the client to stop ibuprofen after developing gastric ulcers, hence no immediate follow-up is needed. Choice D provides important information, but the priority is to address the lack of specificity regarding the client's aspirin use, which is crucial for assessing bleeding risk and potential interactions.

3. 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.

4. A healthcare professional is using an otoscope to inspect the ears of an adult client. Which action does the professional take before inserting the otoscope?

Correct answer: A

Rationale: In an adult client, the healthcare professional should pull the pinna up and back before inserting the otoscope. This action helps straighten the S shape of the ear canal, making it easier to insert the otoscope directly and comfortably. Tipping the client's head down and toward or away from the examiner is not the correct action when using an otoscope in an adult. Pulling the pinna down and forward is typically done when examining an infant or a child younger than 3 years old to straighten their ear canal for better visualization.

5. What is a chemical reaction between drugs before their administration or absorption known as?

Correct answer: A

Rationale: A chemical reaction between drugs before their administration or absorption is termed a drug incompatibility. This phenomenon commonly occurs when drug solutions are mixed before intravenous administration but can also happen with orally administered drugs. Choices B, C, and D are incorrect because side effects, adverse events, and allergic responses typically occur after the drugs have been administered and absorbed, not before.

Similar Questions

A nurse sees documentation in the client's record indicating that the health care provider has noted the presence of adventitious breath sounds. The nurse knows that these types of sounds have which aspect?
During a health assessment, a nurse is assisting with gathering subjective data from a client and plans to ask the client about the medical history of the client's extended family. About which family members would the nurse ask the client?
Which of the following physical findings indicates that an 11-12-month-old child is at risk for developmental dysplasia of the hip?
A nurse monitoring a newborn infant notes that the infant's respirations are 40 breaths/min. On the basis of this finding, what is the most appropriate action for the nurse to take?
Ms. Petty is having difficulty falling asleep. Which of the following measures promote sleep?

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