NCLEX-PN
NCLEX PN Exam Cram Questions
Extract:
Question 1 of 5
A mother brings her 13-month-old child with Down Syndrome to a pediatric clinic reporting muscle weakness and poor movement. The child's reflexes are noted to be diminished. Which action should the nurse take first?
Correct Answer: D
Rationale: In a child with Down Syndrome presenting with muscle weakness and diminished reflexes, an atlanto-axial dislocation is a concern. The priority action is to position the child's neck in a neutral c-spine posture to prevent further injury. This should be done before any movement or manipulation. Contacting the physician should follow to ensure appropriate evaluation and management. Initiating an IV is not indicated unless specifically ordered for a medical reason. Ordering an X-ray for a c-spine work-up should not be the first action as it may involve movement that could exacerbate the condition if an injury is present.
Question 2 of 5
A patient has suffered a left CVA and developed severe hemiparesis resulting in a loss of mobility. The nurse notices on assessment that an area over the patient's left elbow appears as non-blanchable erythema, and the skin is intact. The nurse should score the patient as having which of the following?
Correct Answer: A
Rationale: Erythema with the skin intact is characteristic of a Stage I pressure ulcer. At this stage, the skin is not broken, but there is localized redness that does not blanch when pressed. Stage II pressure ulcers involve partial-thickness skin loss, Stage III pressure ulcers have full-thickness skin loss, and Stage IV pressure ulcers extend to deeper tissues, including muscle and bone. In this case, the non-blanchable erythema with intact skin aligns with the characteristics of a Stage I pressure ulcer.
Question 3 of 5
Ten-year-old Jackie is admitted to the hospital with a medical diagnosis of Rheumatic Fever. She relates a history of 'a sore throat about a month ago.' Bed rest with bathroom privileges is prescribed. Which of the following nursing assessments should be given the highest priority when assessing Jackie's condition?
Correct Answer: C
Rationale: Monitoring Jackie's cardiac status is of the highest priority in a patient with rheumatic fever. Rheumatic fever can lead to permanent cardiac damage, making it crucial to closely monitor the heart. Assessing for signs of carditis, such as murmurs or other cardiac symptoms, is essential. The second priority is evaluating joint symptoms for the presence of polyarthritis and pain, which are common manifestations of rheumatic fever. While assessing Jackie's response to hospitalization is important for her emotional well-being, it is not the highest priority. The presence of a macular rash, although relevant, is not as high a priority as monitoring cardiac status or assessing joint symptoms.
Question 4 of 5
A 46-year-old has returned from a heart catheterization and wants to get up to start walking 3 hours after the procedure. The nurse should:
Correct Answer: A
Rationale: The correct answer is to tell the patient to remain with the leg straight for at least another hour after a heart catheterization before starting ambulation. This period allows for proper healing and reduces the risk of complications such as bleeding or hematoma formation at the catheter insertion site. Starting ambulation too soon can disrupt the healing process and lead to adverse events.
Choice B is incorrect because limited ambulation should not be initiated shortly after the procedure as it may increase the risk of complications.
Choice C is incorrect as physical therapy consultation is not typically necessary for initial ambulation post-heart catheterization; this can be managed by nursing staff.
Choice D is incorrect as keeping the leg straight for 6 hours is excessive and unnecessary, potentially leading to complications such as deep vein thrombosis due to prolonged immobility.
Question 5 of 5
A healthcare provider is caring for a patient who has experienced burns to the right lower extremity. According to the Rule of Nines, which of the following percentages most accurately describes the severity of the injury?
Correct Answer: C
Rationale: According to the Rule of Nines, the right lower extremity accounts for 18% of the total body surface area. The Rule of Nines divides the body into regions, each representing 9% or a multiple of 9%, allowing for a quick estimation of the extent of burns. In this case, the correct answer is 18% as it corresponds to the percentage allocated for each lower extremity.
Choices A, B, and D are incorrect as they do not match the standard allocation for the right lower extremity in the Rule of Nines.