NCLEX-PN
NCLEX PN 2023 Quizlet Questions
Extract:
Question 1 of 5
For a client with suspected appendicitis, in which quadrant should the nurse expect to find abdominal tenderness?
Correct Answer: C
Rationale: The correct answer is C: lower right. Abdominal tenderness in the lower-right quadrant is a classic sign of appendicitis. The appendix is located in the lower right abdomen, so inflammation of the appendix typically causes tenderness in this specific area.
Choices A, B, and D are incorrect because tenderness in the upper right, upper left, and lower left quadrants, respectively, is not typical in appendicitis cases.
Therefore, the nurse should focus on assessing the lower right quadrant for tenderness when suspecting appendicitis.
Question 2 of 5
The client is scheduled for surgical repair of a detached retina. What is the most likely preoperative nursing diagnosis for this client?
Correct Answer: A
Rationale: The correct preoperative nursing diagnosis for a client scheduled for surgical repair of a detached retina is 'Anxiety related to loss of vision and potential failure to regain vision.' A client facing the threat of permanent blindness due to a detached retina is likely to experience anxiety. Addressing this anxiety is crucial before providing education, as severe anxiety can hinder the client's ability to absorb new information. The nurse should offer emotional support, encourage the client to express concerns, and clarify any misconceptions. Acute pain is not a typical symptom of a detached retina, and the risk of infection preoperatively is minimal, making choices C and D less relevant in this scenario.
Question 3 of 5
When assessing a client in the Emergency Department whose membranes have ruptured, the nurse notes that the fluid is a greenish color. What is the cause of this greenish coloration?
Correct Answer: B
Rationale: The correct answer is B: meconium. Greenish amniotic fluid passed when the fetus is in a cephalic (head) presentation might indicate fetal distress. A fetus in the breech presentation passes meconium due to compression on the intestinal tract.
Choice A, blood, is incorrect as blood in the amniotic fluid would present as a different color.
Choice C, hydramnios, refers to an excess of amniotic fluid and would not cause the greenish coloration.
Choice D, caput, is swelling of a newborn's scalp and is not related to the color of the amniotic fluid.
Question 4 of 5
With a breech presentation, the nurse must be particularly alert for which of the following?
Correct Answer: D
Rationale: With a breech presentation, the nurse must be particularly alert for a prolapsed umbilical cord. Prolapsed umbilical cord is a critical emergency situation where the umbilical cord descends into the vagina before the fetal presenting part, leading to compression between the presenting part and the maternal pelvis. This compression can compromise or completely cut off fetoplacental perfusion, endangering the fetus. Immediate delivery should be attempted to save the fetus. Quickening refers to fetal movements felt by the mother, ophthalmia neonatorum is an eye infection in newborns, and pica is a condition characterized by cravings for non-nutritive substances, none of which are directly related to the risks associated with a breech presentation and prolapsed umbilical cord.
Question 5 of 5
A one-month-old infant in the neonatal intensive care unit is dying. The parents request that the nurse administer an opioid analgesic to their infant, who is crying weakly. The infant's heart rate is 68 beats per minute, and the respiratory rate is 18 breaths per minute. The infant is on room air, and the oxygen saturation is 92%. The nurse's response is based on which of the following principles?
Correct Answer: A
Rationale: All patients, regardless of age, have the right to die with dignity and be free from pain. In this case, the parents' request for an opioid analgesic to relieve the child's distress aligns with the principles of palliative care and ensuring comfort. Assisted suicide involves a conscious decision by the individual, which is not applicable to a 1-month-old infant. Both the nurse and the parents have an ethical duty to ensure the infant's comfort and well-being. Withholding opioid analgesia solely to hasten death is not appropriate, as providing pain relief is a crucial aspect of end-of-life care. Opioids can be administered to dying patients at any age to alleviate suffering without the intention of hastening death.
Therefore, providing analgesia during the last days and hours is an ethically appropriate nursing action.
Choices B, C, and D are incorrect because the decision to administer analgesia in this scenario is based on the best interest and comfort of the infant, not concerns about assisted suicide or hastening death. The ethical consideration is to provide compassionate care and alleviate suffering.