NCLEX-PN
NCLEX-PN Quizlet 2023
1. Which of the following observations is most important when assessing a client's breathing?
- A. presence of breathing and pulse rate
- B. breathing pattern and adequacy of breathing
- C. presence of breathing and adequacy of breathing
- D. patient position and adequacy of breathing
Correct answer: C
Rationale: The correct answer is the presence of breathing and adequacy of breathing. It is crucial not only to confirm that the client is breathing but also to ensure that the breathing is adequate for proper oxygenation. Choices A, B, and D are incorrect because while pulse rate, breathing pattern, and patient position are relevant aspects to consider, the most critical observations in assessing a client's breathing are the presence and adequacy of breathing.
2. A client has a 10% dextrose in water IV solution running. He is scheduled to receive his antiepileptic drug, phenytoin (Dilantin), at this time. The nurse knows that the phenytoin:
- A. is given after the D10W is finished.
- B. should be given at the time it is due in the medication port closest to the client.
- C. can be piggybacked into the D10W solution now.
- D. is incompatible with dextrose solutions.
Correct answer: D
Rationale: Phenytoin is incompatible with dextrose solutions as they will precipitate when mixed together. Therefore, it should not be piggybacked into the D10W solution or given through the same port. Instead, normal saline should be used to flush before and after administering phenytoin to prevent any interaction with the dextrose solution. Delaying the administration of an antiepileptic drug like phenytoin to maintain therapeutic blood levels is not recommended, so it should not be given after the D10W is finished or based on the medication port closest to the client. Choice A is incorrect because administering phenytoin after the D10W is finished is not the correct approach due to the incompatibility with dextrose solutions. Choice B is incorrect as the timing of phenytoin administration should not be based on the medication port closest to the client but on compatibility considerations. Choice C is incorrect as piggybacking phenytoin into the D10W solution is not advisable due to the incompatibility issue.
3. A nurse is caring for her clients when her new admit arrives on the unit. What action by the nurse is most appropriate?
- A. Ask the nursing assistant to complete emptying the catheter bag and assess the new admission.
- B. Ask the nursing assistant to take vital signs on the new admit and begin the history until she can get there.
- C. Ask the graduate nurse on the floor to initiate the assessment process until she can get there.
- D. Ask the unit secretary to make the client and family comfortable until she can complete her present task.
Correct answer: C
Rationale: The most appropriate action for the nurse in this situation is to ask the graduate nurse on the floor to initiate the assessment process until she can arrive. Nursing assistants are not qualified to perform assessments, and the unit secretary's role does not involve client assessments. Delegating the assessment to the graduate nurse ensures that a qualified healthcare professional is evaluating the new admission, aligning with the nurse's responsibilities and providing appropriate care.
4. When teaching a patient with COPD pulmonary exercises, what should be done?
- A. Teach pursed-lip breathing techniques.
- B. Encourage repetitive heavy lifting exercises to increase strength.
- C. Limit exercises due to respiratory acidosis.
- D. Take breaks every 10-20 minutes during exercises.
Correct answer: A
Rationale: The correct answer is to teach pursed-lip breathing techniques. Pursed-lip breathing helps to decrease the volume of air expelled by keeping the airways open longer, making it easier for patients with COPD to breathe out. Encouraging heavy lifting exercises (Choice B) is not suitable for patients with COPD as it can lead to increased shortness of breath. Limiting exercises due to respiratory acidosis (Choice C) is not correct; instead, exercises should be tailored to the patient's tolerance. Taking breaks every 10-20 minutes (Choice D) is not specific to the management of COPD pulmonary exercises.
5. While performing wound care to a donor skin graft site, the nurse notes some scabbing at the edges and a black collection of blood. What is the nurse's next action?
- A. Leave the scabbed area alone and apply extra ointment
- B. Notify the physician
- C. Gently remove the debris and re-dress the wound
- D. Apply skin softening lotion for 3 hours and then re-dress
Correct answer: C
Rationale: When the nurse notes scabbing at the edges and a black collection of blood, it indicates the presence of debris that needs to be addressed. Leaving the scabbed area alone and applying extra ointment may not address the underlying issue and could lead to complications. Notifying the physician is important in some cases, but immediate action is required to prevent infection in this situation. Gently removing the debris and re-dressing the wound is the correct course of action to promote healing and prevent complications.
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