NCLEX-PN
NCLEX PN Exam Cram Questions
Extract:
Question 1 of 5
A patient 3 hours post-op from a hysterectomy is complaining of intense pain at the incision site. When assessing the patient, the nurse notes a BP of 169/93, pulse 145 bpm, and regular. What action should the nurse take?
Correct Answer: C
Rationale: The correct action for the nurse to take in this situation is to administer prn Meperidine HCL and assess the client's response. A BP of 169/93 and a pulse of 145 bpm indicate pain-related hypertension and sinus tachycardia, which are physiological responses to pain. Treating the cause of the increased pulse rate requires pain medication. Reassuring the patient about normal post-surgery pain is important, but addressing the physiological responses to pain is a priority. Administering Nifedipine, a calcium channel blocker, is not indicated for pain management but for hypertension. Rechecking the BP and pulse rate without addressing the pain directly does not address the underlying issue causing the elevated vital signs.
Question 2 of 5
What is the best nursing diagnosis for a client with newly diagnosed Diabetes Mellitus?
Correct Answer: B
Rationale: The correct answer is 'Knowledge Deficit: New Diabetes Diagnosis.' Newly diagnosed diabetics require education on their disease, medications, glucose testing, insulin injections, foot care, and sick-day plans.
Choices A and D aim to prevent issues that do not currently exist for the client.
Choice C, 'Alteration in Nutrition: More than Body Requirements,' is not the priority diagnosis for a newly diagnosed diabetic. While nutritional adjustments may be required for type I or type II diabetes, providing knowledge and education takes precedence at this stage.
Question 3 of 5
Which statement best describes electrolytes in intracellular and extracellular fluid?
Correct Answer: A
Rationale: Electrolytes are distributed unequally between intracellular and extracellular fluids. Sodium concentration is higher in extracellular fluid, while potassium concentration is higher in intracellular fluid.
Therefore, the correct answer is 'There is a greater concentration of sodium in extracellular fluid and potassium in intracellular fluid.'
Choices B, C, and D are incorrect because they do not accurately describe the typical distribution of sodium and potassium between intracellular and extracellular fluid.
Question 4 of 5
Which of the following procedures describes an opening between the colon and abdominal wall?
Correct Answer: C
Rationale: A colostomy is an opening between the colon and abdominal wall. An ileostomy is an opening between the ileum and abdominal wall, not the colon. Jejunostomy is an opening between the jejunum and abdominal wall, and cecostomy is an opening into the cecum. The term 'colostomy' specifically refers to the surgical procedure where a part of the colon is brought through the abdominal wall to create a stoma, allowing feces to leave the body.
Therefore, the correct answer is colostomy as it accurately describes the opening between the colon and the abdominal wall, distinct from the other options.
Question 5 of 5
Which of the following is not typically considered one of the main mechanisms of Type II Diabetes treatment?
Correct Answer: D
Rationale: Continuous Insulin is not typically considered one of the main mechanisms for treating Type II Diabetes. While medications, nutrition, and increased activity play crucial roles in managing Type II Diabetes, continuous insulin therapy is more common in Type I Diabetes or in specific cases of Type II Diabetes where other treatments are ineffective.
Therefore, the correct answer is Continuous Insulin.
Choices A, B, and C are mainstays in the treatment of Type II Diabetes, making them incorrect answers.