NCLEX-PN
NCLEX PN Exam Cram
1. A nurse working in a surgical unit notices a patient experiencing SOB, calf pain, and warmth over the posterior calf. All of these symptoms may indicate which of the following medical conditions?
- A. Patient may have a DVT.
- B. Patient may be exhibiting signs of dermatitis.
- C. Patient may be in the late stages of CHF.
- D. Patient may be experiencing anxiety after surgery.
Correct answer: A
Rationale: The correct answer is that the patient may have a DVT (Deep Vein Thrombosis). SOB (Shortness of Breath), calf pain, and warmth over the posterior calf are classic signs and symptoms of DVT. DVT is a serious condition where a blood clot forms in a deep vein, commonly in the legs. Choices B, C, and D are incorrect because dermatitis does not typically present with these symptoms, late stages of CHF would manifest with other signs, and anxiety after surgery usually does not produce these specific symptoms.
2. After applying oxygen using bi-nasal prongs to a client who is having chest pain, the nurse should implement which intervention?
- A. Have the client take slow deep breaths in through their mouth and out through their nose.
- B. Post signs indicating that oxygen is in use on the client's door and in their room
- C. Apply Vaseline petroleum to both nares and 2 by 2 gauze around the oxygen tubing at the client's ears
- D. Encourage the client to hyperextend the neck, take a few deep breaths and cough.
Correct answer: A
Rationale: After applying oxygen using bi-nasal prongs to a client with chest pain, it is essential for the nurse to post signs indicating that oxygen is in use on the client's door and in their room. This safety precaution alerts healthcare providers and visitors that the client is receiving oxygen therapy, reducing the risk of accidents or misunderstandings. Choice A is incorrect because instructing the client to take slow deep breaths is not the appropriate intervention after applying oxygen. Choice C suggests applying Vaseline and gauze, which is unnecessary and not a standard practice. Choice D advising the client to hyperextend the neck, take deep breaths, and cough is not indicated after applying oxygen therapy and could potentially be harmful.
3. A 15-year-old high school wrestler has been taking diuretics to lose weight to compete in a lower weight class. Which of the following medical tests is most likely to be given?
- A. Lab values of Potassium and Sodium
- B. Lab values of Glucose and Hemoglobin
- C. ECG
- D. CT scan
Correct answer: A
Rationale: Diuretics can disrupt the sodium and potassium balance, potentially leading to cardiac complications. Monitoring the lab values of potassium and sodium is crucial to assess electrolyte imbalances due to diuretic use. Testing glucose and hemoglobin levels is not directly related to diuretic use in this context. An ECG would be indicated if there were signs or symptoms of cardiac abnormalities, but it is not the primary test to monitor the effects of diuretics. A CT scan is not typically used to assess electrolyte imbalances caused by diuretics.
4. At what age will vision be 20/20 in children?
- A. 4 years old
- B. 5 years old
- C. 6 years old
- D. 7 years old
Correct answer: C
Rationale: The correct answer is 6 years old. At this age, children typically have the potential for 20/20 vision. This is considered the standard age for achieving optimal vision clarity. Choices A, B, and D are incorrect as they are not typically associated with the age at which children achieve 20/20 vision.
5. What is the next step for a 64-year-old male diagnosed with COPD and CHF who shows a 10 lbs increase in total body weight over the last few days?
- A. Contact the patient's physician immediately.
- B. Check the intake and output on the patient's flow sheet.
- C. Encourage the patient to ambulate to reduce lower extremity edema.
- D. Check the patient's vitals every 2 hours.
Correct answer: B
Rationale: In a patient with COPD and CHF experiencing a sudden increase in total body weight, the priority is to check the intake and output on the patient's flow sheet to evaluate fluid balance. This assessment helps determine if the weight gain is due to fluid retention, which can exacerbate CHF. Contacting the physician may be necessary based on the intake and output findings. While encouraging ambulation is beneficial for circulation, it may not address the root cause of fluid retention. Checking vitals every 2 hours is important for monitoring stability but may not pinpoint the reason behind the weight gain.
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