NCLEX-PN
NCLEX PN Practice Questions Quizlet Questions
Extract:
Question 1 of 5
The home health nurse has made a visit to an 85-year-old female client's home who has recently had surgery to replace her left knee. The client has been discharged from a rehab facility and has been able to walk on her own. The nurse assesses the need for teaching related to fall prevention. What should the nurse include in this teaching plan?
Correct Answer: A
Rationale: The correct answer is to instruct the client to remove all scatter rugs from the floor and minimize clutter. Rugs and clutter are common causes of falls in the home, especially for the elderly or those with gait issues. Removing them can significantly reduce the risk of falls. While having a raised toilet seat and grab bars in the bathroom is important for safety, it is not the priority in this scenario. The client should not limit her movement within the home unless specifically advised by the physician, as maintaining mobility is essential for recovery. Lastly, the client should avoid wearing robes and socks while walking in the house to prevent tripping, slipping, or falling on slippery floors.
Question 2 of 5
A 35-year-old Latin-American client wishes to lose weight to reduce her chances of developing heart disease and diabetes. The client states, "I do not know how to make my diet work with the kind of foods that my family eats."? What should the nurse do first to help the client determine a suitable diet for disease prevention?
Correct Answer: B
Rationale: The correct first step is to assess the client's current diet by asking her to provide a list of the types of foods she eats. This assessment will help the nurse determine a personalized dietary plan based on the guidelines from the American Diabetes Association and the American Heart Association. Providing the client with copies of the guidelines is important but not the initial action. A high-protein diet plan may not be suitable for all clients aiming to prevent heart disease and diabetes. While providing information on risk factors is important, it is not the primary step in assisting the client with determining a suitable diet for disease prevention.
Question 3 of 5
A healthcare professional is reviewing the health care record of a client who has just undergone an examination of the internal genitalia. Which documented finding indicates an abnormality?
Correct Answer: D
Rationale: The correct answer is 'Clear secretions with a foul odor are noted on the cervix.' Normally, the cervix is pink, midline, and about 1 inch in diameter. Depending on the day of the menstrual cycle, secretions may vary. However, they should always be odorless and nonirritating. Secretions with a foul odor are indicative of an infection, making this finding abnormal.
Choices A, B, and C describe normal cervix characteristics, so they do not indicate an abnormality in this scenario.
Question 4 of 5
A nurse is preparing to assess the function of a client's spinal accessory nerve. Which action does the nurse ask the client to take to aid assessment of this nerve?
Correct Answer: C
Rationale:
To assess cranial nerve XI (spinal accessory nerve), the examiner checks the sternomastoid and trapezius muscles for equal size. Equal strength is assessed by asking the client to rotate the head forcibly against resistance applied to the side of the chin and by asking the client to shrug the shoulders against resistance. These movements should feel equally strong on the two sides. The client is asked to smile as a test of the function of cranial nerve VII (facial nerve). The client's ability to clench the teeth is used to assess the motor function of cranial nerve V (trigeminal nerve). The client's taste perception is used to assess the sensory function of cranial nerve IX (glossopharyngeal nerve).
Therefore, the correct action to assess the spinal accessory nerve is to ask the client to shrug the shoulders against resistance. The other options are used to assess different cranial nerves, making them incorrect choices.
Question 5 of 5
Following the change of shift report, when can or should the nurse's plan be altered or modified during the shift?
Correct Answer: C
Rationale: The correct answer is 'when needs change.' It is crucial for the nurse to remain adaptable and adjust the plan promptly when the patient's needs or condition change.
Choice A, 'halfway through the shift,' may not align with the timing of when needs actually change, making it less optimal for plan modifications.
Choice B, 'at the end of the shift before the nurse reports off,' is too late to address evolving needs effectively.
Choice D, 'after the top-priority tasks have been completed,' limits the nurse's ability to respond promptly to changing priorities, as needs may shift before all top-priority tasks are finished.