NCLEX-PN
2024 PN NCLEX Questions Questions
Extract:
Question 1 of 5
A nurse is determining the fetal heart rate (FHR) and places the fetoscope on the mother's abdomen to count the FHR. The nurse simultaneously palpates the mother's radial pulse and notes that it is synchronized with the sounds heard through the fetoscope. Which action should the nurse take?
Correct Answer: B
Rationale: When auscultating the fetal heart rate, the nurse would place the fetoscope on the maternal abdomen, over the fetal back. The nurse would then palpate the mother's radial pulse. If her pulse is synchronized with the sounds from the fetoscope, the nurse would move the fetoscope to another area on the mother's abdomen to locate the FHR. The nurse needs to be sure that the FHR is what is actually being heard. Other sounds that may be heard are the funic sound (blood flowing through the umbilical cord) and the uterine sound (blood flowing through the uterine vessels). The funic sound is synchronized with the FHR; the uterine sound is synchronized with the mother's pulse.
Therefore, moving the fetoscope to a different area will help in accurately locating and counting the fetal heart rate.
Choice A is incorrect because counting for 60 seconds without changing the position may not address the issue of accurately locating the FHR.
Choice C is incorrect as it does not address the need to reposition the fetoscope to locate the fetal heart.
Choice D is incorrect because counting the FHR and the radial pulse rate separately may not help in differentiating the two sounds.
Question 2 of 5
When preparing a client for surgery, the graduate nurse realizes the operative permit has not been signed. The client tells the nurse he understands the procedure but received his preoperative medication approximately 10 minutes prior. The appropriate action would be:
Correct Answer: D
Rationale: The correct action in this scenario is to call the surgical area and explain that the surgery will have to be cancelled. The client must sign the operative permit or any other legal document before receiving preoperative medication. Without the signed permit, the surgery cannot proceed to ensure the client's safety and legal compliance. Having the client sign the permit, witnessing the form after the client signs it, or having someone else sign the form are all inappropriate actions and do not address the legal requirement of the client's signature before receiving preoperative medication.
Question 3 of 5
A nurse is assisting with developing a plan of care for an older client to help maintain an adequate sleep pattern. Which action should the nurse suggest be included in the plan?
Correct Answer: A
Rationale:
To help maintain an adequate sleep pattern in older clients, it is essential to include activities that promote relaxation and a conducive sleep environment. Encouraging bedtime reading or listening to music can help the client unwind and prepare for sleep. Daytime naps should be discouraged to ensure a better nighttime sleep. Social interaction, especially positive interactions, can be beneficial and should not be discouraged. The use of a nightlight can create a safe and comfortable environment for the client, so it should not be discouraged unless specifically contraindicated.
Question 4 of 5
A school nurse provides information to the parents of school-age children regarding appropriate dental care. The nurse tells the parents that their children should perform which action?
Correct Answer: A
Rationale: School-age children are capable of taking responsibility for their own dental hygiene. Establishing good oral health habits during childhood can lead to a lifetime of cavity prevention. The nurse advises the parents that their children should brush with fluoride toothpaste and floss between their teeth after meals and before bedtime. This routine helps maintain good oral health and teaches children the importance of dental care.
Choice A is the correct answer as it emphasizes both brushing and flossing after meals and at bedtime, which are crucial for effective dental care.
Choices B, C, and D are incorrect as they do not stress the significance of both brushing and flossing after meals, which is essential for proper oral hygiene.
Question 5 of 5
When educating an obese client about nutritional needs and weight loss, which of the following should not be included?
Correct Answer: D
Rationale: When educating an obese client about nutritional needs and weight loss, it is important to cover factors such as knowledge of food and food products, the development of a positive mental attitude, and the importance of adequate exercise. These aspects contribute to a holistic approach to weight management. However, recommending the client to start a fast weight-loss diet should not be included. Fast weight-loss diets can be harmful, leading to health risks, nutrient deficiencies, and unsustainable outcomes. It is crucial to advocate for gradual, sustainable weight loss strategies to ensure long-term success and overall well-being.
Therefore, starting a fast weight-loss diet is the least appropriate option among the choices provided.