NCLEX-PN
Nclex 2024 Questions
1. The client returns to the unit from surgery with a blood pressure of 90/50, pulse 132, respirations 30. Which action by the nurse should receive priority?
- A. Continue monitoring the vital signs
- B. Contact the physician
- C. Ask the client how they feel
- D. Ask the LPN to continue post-op care
Correct answer: B
Rationale: The priority action for the nurse is to contact the physician immediately due to the client's abnormal vital signs. A blood pressure of 90/50, pulse of 132, and respirations of 30 indicate instability and require prompt medical attention. Continuing to monitor vital signs, as in choice A, may lead to a delay in necessary interventions. Asking the client how they feel, as in choice C, provides subjective data and does not address the urgent need for medical intervention. Involving the LPN, as in choice D, is not appropriate in this critical situation where the client's condition is unstable and requires immediate physician assessment and intervention.
2. The client is taking rifampin 600mg po daily to treat his tuberculosis. Which action by the nurse indicates understanding of the medication?
- A. Telling the client that the medication will need to be taken with juice
- B. Telling the client that the medication will change the color of the urine
- C. Telling the client to take the medication before going to bed at night
- D. Telling the client to take the medication if night sweats occur
Correct answer: B
Rationale: The correct answer is telling the client that the medication will change the color of the urine. Rifampin can change the color of the urine and body fluid. Teaching the client about these changes is important as the client might think this is a complication. Answer A is incorrect because there is no specific requirement to take rifampin with juice. Answer C is incorrect because rifampin should be taken at consistent times, not necessarily before going to bed. Answer D is incorrect as rifampin should be taken regularly as prescribed, not based on symptoms like night sweats.
3. James returns home from school angry and upset because his teacher gave him a low grade on an assignment. After returning home from school, he kicks the dog. This coping mechanism is known as:
- A. denial
- B. suppression
- C. displacement
- D. fantasy
Correct answer: C
Rationale: Displacement is the transference of emotions, such as anger, to a substitute target that may be less threatening. In this scenario, James redirects his anger from the teacher to the dog. Denial is refusing to acknowledge an aspect of reality. Suppression is consciously putting aside unwanted thoughts or feelings. Fantasy involves imagining unrealistic scenarios. Therefore, in this case, the correct answer is displacement as James displaces his anger towards the dog.
4. After group therapy, the female victim of intimate partner violence confides to the nurse that she does not feel in any immediate danger. Which of the following statements about victims of domestic violence is true?
- A. Victims of domestic violence are often the best predictors of their risk of harm.
- B. Victims of domestic violence often overestimate their safety risk.
- C. Victims of domestic violence are typically in a state of denial.
- D. Victims of domestic violence know that keeping peace with their partner is the best method of preventing another attack.
Correct answer: A
Rationale: Victims of domestic violence are often correct at predicting their risk of harm. It is crucial for the nurse to ensure that the client is expressing herself authentically and not downplaying any potential danger. While victims can be insightful about their risk, it's essential to involve proper authorities, such as the police, in situations of intimate partner violence to ensure safety and provide necessary support. Choice B is incorrect because victims may not necessarily overestimate their safety risk. Choice C is incorrect as not all victims are in a state of denial; some may recognize the dangers they face. Choice D is incorrect because victims may not believe that keeping peace with their partner is the best way to prevent future attacks, as each individual's situation and mindset vary.
5. When assisting a client in gaining insight into anxiety, what should the nurse do?
- A. Help the client relate anxiety to specific triggers.
- B. Ask the client to describe events that precede increased anxiety.
- C. Instruct the client to practice relaxation techniques.
- D. Confront the client's resistive behavior.
Correct answer: B
Rationale: To assist a client in gaining insight into anxiety, it is crucial to identify triggers or events that lead to increased anxiety. This approach helps the client recognize causal factors contributing to their anxiety, promoting self-awareness and understanding. Choice A is incorrect because it should focus on triggers rather than specific behaviors. Choice C is incorrect as it emphasizes managing anxiety through relaxation techniques rather than understanding its roots. Choice D is incorrect as it addresses resistive behavior rather than exploring the causes of anxiety.
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