the nurse receives an assignment of three clients which of the following should the nurse consider as highest priority when determining which client t
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NCLEX-PN

Nclex PN Questions and Answers

1. The nurse receives an assignment of three clients. Which of the following should the nurse consider as the highest priority when determining which client to assess first?

Correct answer: D

Rationale: The nurse should prioritize assessing a client with a potential airway obstruction first based on the ABCs (airway, breathing, circulation) principle. Maintaining a clear airway is crucial for oxygenation and ventilation, making it the highest priority. Choices A and B focus on call bells and waiting times, which are important but not life-threatening in comparison to airway concerns. While pain management is essential, it takes precedence after addressing immediate life-threatening issues like airway compromise.

2. The nurse is teaching a teenage female about preventing the transmission of genital herpes. Which of the following statements should the nurse include?

Correct answer: C

Rationale: Genital herpes can be transmitted through oral, genital, and anal sex. It's crucial to understand that the infection can be spread through intercourse even when symptoms are not present. Option A is incorrect because genital herpes is not transmitted through toilet seats. Option B is correct as oral sex can transmit the virus. Option D is incorrect as drinking fluids after sex does not prevent the transmission of genital herpes.

3. When assessing a client's mobility status, the physical examination should start with:

Correct answer: A

Rationale: When assessing a client's mobility status, it is crucial to start by examining their gait. Gait assessment is usually conducted as the client walks into the room. Normal gait is described as smooth, flowing, and rhythmic without the need for assistive devices. Choices B, C, and D are incorrect as they do not represent the standard practice of beginning the assessment of mobility status with gait examination.

4. Acyclovir (Zovirax) is the agent of choice for which of the following infections?

Correct answer: D

Rationale: Acyclovir is an antiviral medication specifically effective in treating herpes infections. It works by inhibiting the replication of the herpes virus, shortening the duration of the infection. While Acyclovir can be used in HIV and AIDS patients to treat opportunistic viral infections, it is not a primary drug for managing HIV or AIDS itself. Candida is a type of fungus, and infections caused by Candida are treated with antifungal medications, not antivirals like Acyclovir. Therefore, the correct answer is herpes.

5. A client with an ileus is placed on intestinal tube suction. Which of the following electrolytes is lost with intestinal suction?

Correct answer: D

Rationale: When a client with an ileus is placed on intestinal tube suction, the primary electrolyte lost is sodium chloride. Duodenal intestinal fluid contains potassium (K+), sodium (Na+), and bicarbonate. Suctioning is done to remove excess fluids, leading to a decrease in the client's sodium chloride levels. Therefore, options A, B, and C are incorrect as calcium, magnesium, and potassium are not the primary electrolytes lost during intestinal suction in a client with an ileus.

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