NCLEX-PN
Quizlet NCLEX PN 2023 Questions
Extract:
Question 1 of 5
Paula is a 32-year-old woman seeking evaluation and treatment for major depressive symptoms. A major nursing priority during the assessment process includes which of the following?
Correct Answer: B
Rationale: The correct answer is to consider the possibility of self-harm during the assessment process. This is crucial because unless the client is first assessed for self-harm or suicide potential, the necessary degree of vigilance in the client's environment may not be observed. While understanding the meaning of current stressors is important for treatment planning, ensuring the client's safety takes precedence. Motivation to participate in treatment and the presence of alcohol or other drug use are also important aspects to assess but ensuring the client's safety is the top priority in this scenario.
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
When giving an intramuscular injection to an infant, which of the following sites is preferred?
Correct Answer: C
Rationale: The correct answer is the Vastus lateralis when giving an intramuscular injection to an infant. The Vastus lateralis muscle, located in the thigh, is the preferred site for infants as it has a larger muscle mass and is well-developed, making it suitable for injections. The Ventrogluteal region and Dorsogluteal region are not recommended for infants due to their smaller muscle mass and potential risk of damaging nearby structures. The Deltoid muscle is typically used for older children and adults, not infants.
Question 4 of 5
A nurse gave medications to the wrong client. She stated the client responded to the name called. What is the nurse's appropriate documentation?
Correct Answer: D
Rationale: In the case where medications are given to the wrong client, the appropriate documentation by the nurse should involve completely filling out an incident report. This report is essential for tracking errors, implementing corrective measures, and ensuring patient safety.
Choice A is incorrect because solely noting the drug given does not address the severity of the error.
Choice B is incorrect because even if the client was not hurt, documentation is crucial for quality improvement and risk prevention.
Choice C is incorrect as noting the client's orientation does not adequately address the medication error and its implications.
Question 5 of 5
A patient has experienced a severe third-degree burn to the trunk in the last 36 hours. Which phase of burn management is the patient in?
Correct Answer: A
Rationale: The correct answer is A: Shock phase. The shock phase occurs within the first 24-48 hours of burn management. During this phase, the focus is on stabilization, fluid resuscitation, and monitoring for potential complications.
Choice B, the Emergent phase, is incorrect as it refers to the initial phase of burn care immediately after the injury.
Choice C, the Healing phase, occurs later in the treatment process when the wound starts to repair itself.
Choice D, the Wound proliferation phase, is not a recognized phase in burn management.