NCLEX-PN
NCLEX PN Exam Cram
1. Which of the following procedures describes an opening between the colon and abdominal wall?
- A. ileostomy
- B. jejunostomy
- C. colostomy
- D. cecostomy
Correct answer: C
Rationale: A colostomy is an opening between the colon and abdominal wall. An ileostomy is an opening between the ileum and abdominal wall, not the colon. Jejunostomy is an opening between the jejunum and abdominal wall, and cecostomy is an opening into the cecum. The term 'colostomy' specifically refers to the surgical procedure where a part of the colon is brought through the abdominal wall to create a stoma, allowing feces to leave the body. Therefore, the correct answer is colostomy as it accurately describes the opening between the colon and the abdominal wall, distinct from the other options.
2. Which statement best describes electrolytes in intracellular and extracellular fluid?
- A. There is a greater concentration of sodium in extracellular fluid and potassium in intracellular fluid
- B. There is an equal concentration of sodium and potassium in extracellular fluid
- C. There is a greater concentration of potassium in extracellular fluid and sodium in intracellular fluid
- D. There is an equal concentration of sodium and potassium between intracellular and extracellular fluid
Correct answer: A
Rationale: Electrolytes are distributed unequally between intracellular and extracellular fluids. Sodium concentration is higher in extracellular fluid, while potassium concentration is higher in intracellular fluid. Therefore, the correct answer is 'There is a greater concentration of sodium in extracellular fluid and potassium in intracellular fluid.' Choices B, C, and D are incorrect because they do not accurately describe the typical distribution of sodium and potassium between intracellular and extracellular fluid.
3. A patient has been diagnosed with Guillain-Barre Syndrome. Which of the following statements is the most applicable when discussing the impairments with Guillain-Barre Syndrome with the patient?
- A. Guillain-Barre Syndrome improves in almost all cases within 5 years.
- B. Guillain-Barre Syndrome causes limited sensation in the abdominal region.
- C. Guillain-Barre Syndrome causes muscle weakness in the legs.
- D. Guillain-Barre Syndrome affects breathing in severe cases.
Correct answer: C
Rationale: The correct statement is that Guillain-Barre Syndrome causes muscle weakness in the legs. This muscle weakness typically starts in the legs and can progress to the upper body. Choice A is incorrect as while most cases do improve, the recovery time can vary. Choice B is incorrect as Guillain-Barre Syndrome primarily affects muscle weakness rather than sensation. Choice D is incorrect as severe cases of Guillain-Barre Syndrome can lead to respiratory muscle weakness, impacting breathing.
4. The client with a history of advanced chronic obstructive pulmonary disease (COPD) had conventional gallbladder surgery 2 days previously. Which intervention has priority for preventing respiratory complications?
- A. Incentive spirometry every 1 to 2 hours.
- B. Coughing and deep breathing every 1 to 2 hours.
- C. Getting the client out of bed 4 times daily as ordered by the physician.
- D. Giving oxygen at 4 L/minute according to the physician's order.
Correct answer: C
Rationale: The priority intervention for preventing respiratory complications in a client with advanced COPD who underwent gallbladder surgery is to get the client out of bed 4 times daily. This helps prevent pooling of secretions in the lungs and promotes better lung expansion. Incentive spirometry, coughing, and deep breathing are essential interventions; however, they should be performed more frequently, ideally every 1 to 2 hours, rather than every 4 hours or 4 times daily. Giving oxygen at 4 L/minute could potentially decrease the client's respiratory drive, which is not the priority in this case.
5. The anemias most often associated with pregnancy are:
- A. folic acid and iron deficiency.
- B. folic acid deficiency and thalassemia.
- C. iron deficiency and thalassemia.
- D. thalassemia and B12 deficiency.
Correct answer: B
Rationale: Folic acid and iron deficiency anemia are the most common types of anemia associated with pregnancy. Approximately 50% of pregnant women experience this type of anemia. Iron deficiency anemia during pregnancy typically results from the increased plasma volume, rather than a decrease in iron levels. Moreover, if a woman has iron deficiency anemia before pregnancy, it often worsens during pregnancy. Folic acid deficiency is also prevalent during pregnancy due to the increased demand for this nutrient to support fetal development. Thalassemia and B12 deficiency, while types of anemia, are not as commonly associated with pregnancy compared to folic acid and iron deficiency anemia, making them incorrect choices in this context.
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