NCLEX-PN
2024 PN NCLEX Questions Questions
Extract:
Question 1 of 5
A nurse is preparing to assess the fetal heart rate (FHR) of a client who is 14 weeks pregnant. Which piece of equipment does the nurse use to assess the FHR?
Correct Answer: B
Rationale:
To assess the fetal heart rate of a client who is 14 weeks pregnant, the nurse should use a Doppler transducer. Fetal heart sounds can be heard with a fetoscope by 20 weeks of gestation. The Doppler transducer amplifies fetal heart sounds so that they are audible by 10 to 12 weeks of gestation, making it the most appropriate choice for this scenario. Fetal heart sounds cannot be heard with a stethoscope. Pulse oximetry is not used to auscultate fetal heart sounds, so it is an incorrect choice in this context.
Question 2 of 5
The mother of an adolescent calls the clinic nurse and reports that her daughter wants to have her navel pierced. The mother asks the nurse about the dangers associated with body piercing. The nurse provides which information to the mother?
Correct Answer: C
Rationale: Generally, body piercing is harmless if the procedure is performed under sterile conditions by a qualified person. Some complications that may occur include bleeding, infection, keloid formation, and the development of allergies to metal. It is essential to clean the area at least twice a day (more often for a tongue piercing) to prevent infection. HIV and hepatitis B infections are not typically associated with body piercing; however, they are a possibility with tattooing.
Choice A is incorrect because infection does not always occur when body piercing is done.
Choice B is not the best answer as hepatitis B is not commonly associated with body piercing.
Choice D is incorrect because the risk of contracting HIV is not a significant concern with body piercing if performed under sterile conditions.
Question 3 of 5
A nurse is assisting with data collection regarding skin and peripheral vascular findings on a client in later adulthood. Which observation would the nurse expect to note as an age-related finding?
Correct Answer: C
Rationale: In later adulthood, age-related findings include trophic changes associated with arterial insufficiency, such as thin, shiny skin; thin, ridged toenails; and loss of hair on the lower legs. These changes occur normally with aging. Thick skin on the lower legs would not be an expected age-related finding as it typically indicates chronic venous insufficiency. A bounding dorsalis pedis pulse is not typical in later adulthood and may indicate arterial insufficiency, which is not an age-related finding.
Question 4 of 5
A sexually active married couple, discussing birth control methods with the nurse, expresses the need for a method that is convenient. Because the couple has told the nurse that family-planning goals have been met, which method of birth control does the nurse suggest?
Correct Answer: B
Rationale: In this scenario, since the couple has indicated that their family-planning goals have been met, a permanent method of contraception like sterilization would be most suitable. Sterilization offers long-term effectiveness and convenience once the decision to stop having children is made. Options like the diaphragm, male condom, or spermicide are more suitable for temporary contraception or when the family-planning goals have not yet been achieved.
Therefore, the correct answer is sterilization, as it aligns with the couple's need for a convenient and permanent birth control method.
Question 5 of 5
During a well-baby examination, the nurse measures the head circumference, and it is the same as the chest circumference. On the basis of this measurement, what action should the nurse take?
Correct Answer: A
Rationale: The head circumference growth rate during the first year is approximately 0.4 inches (1 cm) per month. By 10 to 12 months of age, the infant's head and chest circumferences are equal. In this case, where the head circumference matches the chest circumference, it is a normal finding in infants around 10-12 months.
Therefore, the most appropriate action is to document these measurements in the infant's health care record. Suspecting hydrocephalus or suggesting a skull x-ray would be premature and not indicated based on this measurement. Similarly, telling the mother that the infant is growing faster than expected is not accurate and could cause unnecessary concern.