NCLEX-PN
Nclex Practice Questions 2024 Questions
Extract:
Question 1 of 5
The client with cirrhosis of the liver is receiving Lactulose. The nurse is aware that the rationale for the order for Lactulose is:
Correct Answer: C
Rationale: Lactulose is administered to the client with cirrhosis to lower ammonia levels, as it works by acidifying the colon, trapping ammonia for elimination in the stool.
Choices A, B, and D are incorrect because Lactulose does not have an effect on blood glucose, uric acid, or creatinine levels.
Therefore, the correct answer is to lower the ammonia level.
Question 2 of 5
A new nursing graduate indicates in charting entries that he is a licensed practical nurse, although he has not yet received the results of the licensing exam. The graduate's action can result in what type of charge?
Correct Answer: A
Rationale: The correct answer is 'Fraud.' Identifying oneself as a nurse without a license defrauds the public and can lead to prosecution. A tort is a wrongful act in breach of a legal duty imposed by law; malpractice is the failure to act appropriately as a nurse or acting in a way that harm comes to the client; and negligence is failing to perform care. In this scenario, the key issue is the misrepresentation of licensure status, which constitutes fraud.
Therefore, choices B, C, and D are incorrect.
Question 3 of 5
A client reports that he is 'talking to the voices.' The nurse observes this behavior. The nurse's next action should be:
Correct Answer: A
Rationale: When a client reports talking to voices, the nurse should engage in a gentle touch to help the client return to reality. It is important for the nurse to acknowledge the client's experience and attempt to redirect them gently.
Touch can provide grounding and connection. Asking the client to describe what is happening can be overwhelming and might exacerbate the situation. Leaving the client alone may not be safe or therapeutic as the client may need support. Telling the client there are no voices denies their reality and is not helpful in managing their experience.
Question 4 of 5
The client is scheduled for a Tensilon test to check for Myasthenia Gravis. Which medication should be kept available during the test?
Correct Answer: A
Rationale: During a Tensilon test to check for Myasthenia Gravis, Atropine sulfate should be kept available as it is the antidote for Tensilon and is administered to manage cholinergic crises that may occur during the test. Atropine sulfate helps counteract the excessive stimulation of the parasympathetic nervous system caused by Tensilon. Furosemide (choice
B) is a diuretic and not related to managing Tensilon-induced crises. Prostigmin (choice
C) is used to treat Myasthenia Gravis itself, not for managing the effects of Tensilon. Promethazine (choice
D) is an antiemetic and antianxiety agent, which is not necessary for a Tensilon test.
Therefore, Atropine sulfate (choice
A) is the correct medication to have available during a Tensilon test, making choices B, C, and D incorrect in this context.
Question 5 of 5
Upon arrival at the emergency room, the client presents with severe burns to the left arm, hands, face, and neck. What action should take priority?
Correct Answer: B
Rationale: In a client with severe burns to the face and neck, airway assessment and supplemental oxygen are crucial.
Therefore, applying oxygen is the priority to ensure adequate oxygenation for the client. This intervention takes precedence over other actions to stabilize the client's condition. Starting an IV for fluid resuscitation is the next appropriate step following ensuring oxygenation (
Choice
A). While pain management is important, it is a secondary priority after ensuring oxygenation and fluid resuscitation, making medicating the client for pain a later intervention (
Choice
D). Obtaining blood gases (
Choice
C) is not the immediate priority in this scenario and would typically be ordered by the healthcare provider based on the client's condition and response to initial interventions.