NCLEX-PN
Quizlet NCLEX PN 2023 Questions
Extract:
Question 1 of 5
A nurse is teaching a client newly diagnosed with Emphysema about the disease process. Which of the following statements best explains the problems associated with emphysema and could be adapted for use in the nurse's discussion with the client?
Correct Answer: B
Rationale: The correct answer is: 'Larger than normal air spaces and loss of elastic recoil cause air to be trapped in the lung and collapse airways.' Emphysema is a breakdown of the elastin and fiber network of the alveoli where the alveoli enlarge or the walls are destroyed. This alveolar destruction leads to the formation of larger-than-normal air spaces. Emphysema is one of a group of pulmonary diseases of a chronic nature characterized by increased resistance to airflow; the entity is part of chronic obstructive pulmonary disease (COP
D).
Choice A is incorrect because emphysema is not primarily characterized by hyperactivity of the medium-sized bronchi causing wheezing and tightness in the chest.
Choice C is incorrect because vasodilation, congestion, and mucosal edema are not the primary mechanisms involved in emphysema, and they do not directly lead to chronic cough and sputum production.
Choice D is incorrect because emphysema is not related to chloride transport issues and thick viscous mucus production.
Question 2 of 5
A nurse is caring for a patient in the step-down unit. The patient has signs of increased intracranial pressure. Which of the following is not a sign of increased intracranial pressure?
Correct Answer: B
Rationale: The correct answer is 'Increased pupil size bilaterally.' When assessing for signs of increased intracranial pressure, bilateral pupil dilation is not typically associated with this condition. Instead, unilateral pupil changes, especially one pupil becoming dilated or non-reactive while the other remains normal, are indicative of increased ICP. Bradycardia, a change in level of consciousness (LO
C), and vomiting are commonly seen in patients with increased intracranial pressure due to the brain's response to the rising pressure.
Therefore, the presence of bilateral pupil dilation goes against the typical pattern observed in patients with increased intracranial pressure.
Question 3 of 5
A client is 36 hours post-op a TKR surgery. 270 cc of sero-sanguinous fluid accumulates in the surgical drains. What action should the nurse take?
Correct Answer: A
Rationale: The correct action for the nurse to take in this situation is to notify the doctor. Significant sero-sanguinous drainage after TKR surgery could indicate a potential issue such as infection or bleeding. The physician needs to be informed promptly to assess the situation and determine the appropriate course of action. Emptying the drain, doing nothing, or removing the drain without consulting the physician could lead to complications going unnoticed or untreated. It is crucial to involve the physician in decision-making to ensure the best outcomes for the client.
Question 4 of 5
In Parkinson's disease, a client's difficulty in performing voluntary movements is known as:
Correct Answer: C.
Rationale: In Parkinson's disease, the client's difficulty in performing voluntary movements is termed dyskinesia. Dyskinesia refers to the impairment of the ability to execute voluntary muscle movements. Akinesia, on the other hand, refers to the absence or lack of voluntary movement. Chorea is characterized by involuntary, rapid, irregular movements. Dystonia involves sustained muscle contractions resulting in abnormal postures or twisting movements.
Therefore, dyskinesia is the specific term used for the described difficulty in Parkinson's disease.
Question 5 of 5
In a client with asthma who develops respiratory acidosis, what should the nurse expect the client's serum potassium level to be?
Correct Answer: B
Rationale: In respiratory acidosis, the serum potassium level is expected to be elevated. This occurs because potassium shifts from cells into the bloodstream as a compensatory mechanism to maintain acid-base balance.
Choices A, C, and D are incorrect. A normal potassium level is not expected in respiratory acidosis. A low potassium level is more commonly associated with alkalosis, not acidosis. The potassium level is indeed related to pH changes in respiratory acidosis, leading to the expected elevation.