NCLEX-PN
Nclex 2024 Questions Questions
Question 1 of 5
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?
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.
Question 2 of 5
A home health nurse is planning for her daily visits. Which client should the home health nurse visit first?
Correct Answer: C
Rationale: The correct answer is the client with laryngeal cancer who had a laryngectomy. This client is at risk for airway obstruction due to the surgical procedure, making it a priority visit. Clients with AIDS (choice
A), a fractured femur (choice
B), and diabetic ulcers (choice
D) do not have immediate life-threatening conditions that require urgent attention compared to a client with a recent laryngectomy.
Question 3 of 5
A client is admitted to the acute care unit. Initial laboratory values reveal serum sodium of 170meq/L. What behavior changes would be most common for this client?
Correct Answer: B
Rationale: The correct answer is 'Mania.' A client with a serum sodium level of 170 meq/L has hypernatremia, which can lead to manic behavior. Hypernatremia is associated with irritability, restlessness, confusion, and in severe cases, manic symptoms.
Choices A, C, and D (Anger, Depression, Psychosis) are not typically associated with hypernatremia and are, therefore, incorrect in this context.
Question 4 of 5
Several clients are admitted to the emergency room following a three-car vehicle accident. Which clients can be assigned to share a room in the emergency department during the disaster?
Correct Answer: B
Rationale: The correct answer is to assign the client who is 6 months pregnant with abdominal pain and the client with facial lacerations and a broken arm to share a room. The pregnant client needs close monitoring due to the abdominal pain, and the client with facial lacerations and a broken arm requires immediate attention for wound care and possible fracture management.
Choice A should not be assigned together as the schizophrenic client experiencing visual and auditory hallucinations needs a separate room for privacy and safety, and the client with ulcerative colitis may require isolation due to the risk of infection.
Choice C is incorrect because the child with fixed and dilated pupils is likely in a critical condition and should be in a private room with parents, while the client with a frontal head injury needs a separate room for focused care.
Choice D is also incorrect as the client with a large puncture wound to the abdomen needs immediate attention in a separate room, and the client with chest pain requires evaluation and monitoring in a separate setting as well.
Question 5 of 5
What should the charge nurse do after overhearing the patient care assistant speaking harshly to the client with dementia?
Correct Answer: B
Rationale: The best action for the charge nurse to take is to explore the interaction with the patient care assistant. This step allows for clarification of the situation and direct addressing of the issue. Changing the patient care assistant's assignment (choice
A) might be necessary, but understanding the situation should come first. Discussing the matter with the client's family (choice
C) as an initial step could escalate the situation. Initiating a group session with the patient care assistant (choice
D) could be considered later as a preventive measure to avoid similar incidents in the future.