NCLEX-PN
NCLEX PN Exam Cram Questions
Extract:
Question 1 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 2 of 5
A patient had a pneumonectomy to the right lung performed 48 hours ago. Which of the following conditions most likely exists?
Correct Answer: A
Rationale: After a pneumonectomy, where a lung is surgically removed, there will be a decrease in breath sound volume on the affected side due to reduced airflow. This reduction in breath sound volume is expected as there is less lung tissue to produce sound.
Choices B, C, and D are incorrect. Elevated tidal volume and respiratory capacity are not expected after a pneumonectomy, and wheezing is more commonly associated with conditions like asthma or bronchitis, not a recent pneumonectomy.
Question 3 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.
Question 4 of 5
A nurse working in a surgical unit notices a patient experiencing SOB, calf pain, and warmth over the posterior calf. All of these symptoms may indicate which of the following medical conditions?
Correct Answer: A
Rationale: The correct answer is that the patient may have a DVT (Deep Vein Thrombosis). SOB (Shortness of Breath), calf pain, and warmth over the posterior calf are classic signs and symptoms of DVT. DVT is a serious condition where a blood clot forms in a deep vein, commonly in the legs.
Choices B, C, and D are incorrect because dermatitis does not typically present with these symptoms, late stages of CHF would manifest with other signs, and anxiety after surgery usually does not produce these specific symptoms.
Question 5 of 5
Which of the following should not be included in the teaching for clients who take oral iron preparations?
Correct Answer: A
Rationale: The correct answer is to mix the liquid iron preparation with antacids to reduce GI distress. This statement is incorrect because iron should not be mixed with antacids as it can significantly reduce the absorption of iron.
Choice B is a good recommendation as taking iron with meals can help reduce gastrointestinal distress.
Choice C is also correct as liquid forms of iron should be taken with a straw to prevent the discoloration of tooth enamel.
Choice D is incorrect as iron preparations can be taken with juice or water, but not with milk, as calcium in milk can inhibit iron absorption.