NCLEX-PN
NCLEX PN 2023 Quizlet
1. A nurse is taking the health history of an 85-year-old client. Which of the following physical findings is consistent with normal aging?
- A. Increase in subcutaneous fat.
- B. Diminished cough reflex.
- C. Long-term memory loss.
- D. Myopia.
Correct answer: B
Rationale: The correct answer is 'Diminished cough reflex.' Diminished cough reflex is a physical finding consistent with normal aging in older adults, which can increase the risk of aspiration and atelectasis. An increase in subcutaneous fat actually raises the risk of pressure ulcers. While long-term memory is typically preserved in aging unless affected by dementia, short-term memory often declines. Myopia (near-sightedness) is common in younger individuals, but presbyopia (far-sightedness) is more common with aging. Additionally, individuals with myopia may experience an improvement in vision as they age.
2. The nurse is providing post-operative care to the craniotomy client. Diabetes insipidus is suspected when the client's urine output suddenly increases significantly. Which action takes highest priority?
- A. Continue to monitor urine output
- B. Check a pulse
- C. Check a blood pressure
- D. Check level of consciousness (LOC)
Correct answer: C
Rationale: The correct answer is to check a blood pressure. Diabetes insipidus can lead to dehydration and potential hypovolemic shock due to excessive urine output. Monitoring blood pressure is crucial to assess the client's circulatory status and detect signs of shock early. Checking the blood pressure will provide essential information on perfusion, which is vital in this situation. Continuing to monitor urine output, checking a pulse, or assessing the level of consciousness are important but not as high a priority as evaluating the blood pressure in a potentially critical situation like suspected diabetes insipidus.
3. The client develops a tension pneumothorax. Assessment is expected to reveal?
- A. Sudden hypertension and bradycardia
- B. Productive cough with yellow mucus
- C. Tracheal deviation and dyspnea
- D. Sudden development of profuse hemoptysis and weakness
Correct answer: C
Rationale: In a tension pneumothorax, the trachea deviates to the unaffected side due to increased pressure in the affected pleural space, causing respiratory distress. Dyspnea is a hallmark symptom as the lung on the affected side collapses, leading to difficulty in breathing. Sudden hypertension and bradycardia (Choice A) are not typical findings of tension pneumothorax. Productive cough with yellow mucus (Choice B) is more suggestive of respiratory infections rather than a tension pneumothorax. Sudden development of profuse hemoptysis and weakness (Choice D) is not characteristic of tension pneumothorax presentation.
4. Which of the following medications is a serotonin antagonist that might be used to relieve nausea and vomiting?
- A. metoclopramide (Reglan)
- B. ondansetron (Zofran)
- C. hydroxyzine (Vistaril)
- D. prochlorperazine (Compazine)
Correct answer: B
Rationale: Zofran is a serotonin antagonist commonly used to relieve nausea and vomiting by blocking serotonin receptors. Metoclopramide (Reglan) acts on dopamine receptors, hydroxyzine (Vistaril) is an antihistamine, and prochlorperazine (Compazine) is a dopamine antagonist. While these medications can also be used for nausea and vomiting, they do not primarily function as serotonin antagonists like ondansetron.
5. What happens if folic acid is administered to treat anemia without determining its underlying cause?
- A. Erythropoiesis is inhibited
- B. Excessive levels of folic acid might accumulate, causing toxicity
- C. The symptoms of pernicious anemia might be masked, delaying treatment
- D. Intrinsic factor is destroyed
Correct answer: C
Rationale: When folic acid is given without determining the underlying cause of anemia, the symptoms of pernicious anemia may be masked, potentially delaying the correct treatment. Folic acid alone does not protect against the central nervous system changes seen in pernicious anemia, which are related to Vitamin B12 deficiency. Folic acid and Vitamin B12 are both crucial for cell growth and division. Administering folic acid without knowing the specific type of anemia could lead to a delay in addressing the root cause. Option A is incorrect because folic acid is essential for erythropoiesis, the production of red blood cells. Option B is incorrect as excessive folic acid can cause toxicity, but it is not the primary concern in this context. Option D is incorrect because folic acid treatment for anemia does not directly impact intrinsic factor, which is related to Vitamin B12 absorption.
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