NCLEX-PN
Quizlet NCLEX PN 2023 Questions
Extract:
Question 1 of 5
During a screening on a patient with a recent cast on the left lower extremity, which of the following statements should the nurse be most concerned about?
Correct Answer: B
Rationale: The correct answer is B because pain in the left calf could indicate a potential neurovascular complication related to the casted extremity. It could suggest issues such as compartment syndrome or impaired circulation. Option A is not as concerning since not elevating the extremity may lead to swelling but is not an immediate concern. Option C indicates itching, which is common with casts and not as concerning as potential neurovascular issues. Option D, regarding arthritis in the wrists, is unrelated to the lower extremity issue being screened for.
Question 2 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.
Question 3 of 5
Laboratory tests reveal the following electrolyte values for Mr. Smith: Na 135 mEq/L, Ca 8.5 mg/dL, Cl 102 mEq/L, and K 2.0 mEq/L. Which of the following values should the nurse report to the physician because of its potential risk to the client?
Correct Answer: B
Rationale: The correct answer is 'K.' Normal serum potassium levels range between 3.5 and 5.5 mEq/L. Mr. Smith's potassium level of 2.0 mEq/L is significantly below the normal range, indicating hypokalemia, which can lead to serious risks such as cardiac arrhythmias. The levels of sodium (Na), calcium (Ca), and chloride (Cl) are within normal ranges, so they do not pose an immediate risk to the client's health.
Therefore, the nurse should report the low potassium level to the physician for prompt intervention.
Question 4 of 5
A newborn baby exhibits a reflex that includes hand opening, abducted, and extended extremities following a jarring motion. Which of the following correctly identifies the reflex?
Correct Answer: D
Rationale: The Moro reflex, also known as the startle reflex, is the correct answer. This reflex is characterized by the baby's response to a sudden head movement or loud noise, causing them to open their hands, extend their arms, and then bring them back towards their body. The characteristics mentioned in the question - hand opening, abducted, and extended extremities following a jarring motion - align with the Moro reflex. The asymmetrical tonic neck reflex (ATNR) involves the head turning to one side with extension of the same side's arm and leg, not the described characteristics. The grasping reflex involves the baby's response to touch on the palm, causing them to grasp an object. While the Moro reflex is often referred to as the startle reflex due to its response to sudden stimuli, the specific characteristics described in the question match the Moro reflex.
Question 5 of 5
A patient has fallen off a bicycle and fractured the head of the proximal fibula. A cast was placed on the patient's lower extremity. Which of the following is the most probable result of the fall?
Correct Answer: A
Rationale: The correct answer is peroneal nerve injury. The head of the proximal fibula is in close proximity to the peroneal nerve, making it susceptible to injury when there is a fracture. The peroneal nerve runs along the fibula and can be affected by trauma to this area.
Choice B, tibial nerve injury, is incorrect as the fracture site is closer to the peroneal nerve, not the tibial nerve.
Choice C, sciatic nerve injury, is incorrect as the injury is more localized to the fibular head area where the peroneal nerve is affected.
Choice D, femoral nerve injury, is incorrect as the femoral nerve is not immediately adjacent to the proximal fibula and is not typically affected by this type of injury.