NCLEX-PN
Nclex Practice Questions 2024 Questions
Extract:
Question 1 of 5
To ensure safety while administering a nitroglycerine patch, what should the nurse do?
Correct Answer: A
Rationale:
To protect herself, the nurse should wear gloves when applying a nitroglycerine patch or cream. Answer B is incorrect because shaving the area where the patch will be applied might abrade the skin, increasing the risk of irritation. Answer C is incorrect because washing with hot water can vasodilate the skin, potentially increasing the absorption of nitroglycerine. Nitroglycerine patches should be applied to areas above the waist, making answer D incorrect as applying it to the buttocks is not recommended.
Question 2 of 5
The nurse is caring for a client scheduled for removal of a pituitary tumor using the transsphenoidal approach. The nurse should be particularly alert for:
Correct Answer: A
Rationale: During the removal of a pituitary tumor using the transsphenoidal approach, nasal congestion is a significant concern as it can further obstruct the airway. This can be due to mucosal swelling, bleeding, or edema resulting from the surgery. Nasal congestion requires immediate attention to prevent airway compromise. Abdominal tenderness, muscle tetany, and oliguria are not directly associated with the pituitary gland or the transsphenoidal approach, making them incorrect choices. Abdominal tenderness is more common in abdominal or pelvic surgeries due to intra-abdominal issues. Muscle tetany is related to electrolyte imbalances or neuromuscular disorders, not specific to pituitary surgery. Oliguria is a concern in renal-related conditions, not typically in pituitary tumor surgeries.
Question 3 of 5
After the client discusses her relationship with her father, the nurse says, "Tell me whether I am understanding your relationship with your father. You feel dominated and controlled by him?"? This is an example of:
Correct Answer: B
Rationale: Seeking consensual validation is the correct answer. Consensual validation is a technique used to check one's understanding of what the client has said. It involves confirming with the client whether the nurse's interpretation aligns with the client's feelings or thoughts. This process helps build rapport, trust, and a shared understanding between the nurse and the client. Verbalizing the implied (choice
A) refers to expressing the underlying or implicit meaning of a client's statement. Encouraging evaluation (choice
C) involves prompting the client to assess or judge a situation. Suggesting collaboration (choice
D) entails proposing working together with the client on a shared goal, which is not the primary focus in the scenario provided.
Question 4 of 5
A client with cancer develops xerostomia. The nurse can help alleviate the discomfort associated with xerostomia by:
Correct Answer: D
Rationale: Xerostomia is dry mouth, a common side effect in cancer patients. Providing a saliva substitute helps alleviate the discomfort associated with dry mouth by moistening the oral mucosa. Offering hard candy, as mentioned in choice A, can worsen xerostomia by increasing sugar content and potentially causing irritation. Administering analgesic medications, as in choice B, is not directly related to treating dry mouth. Splinting swollen joints, as in choice C, is irrelevant to xerostomia, which primarily affects the oral cavity.
Question 5 of 5
The nurse is participating in discharge teaching for the postpartal client. The nurse is aware that an effective means of managing discomfort associated with an episiotomy after discharge is:
Correct Answer: C
Rationale: A sitz bath is an effective method for managing discomfort associated with an episiotomy after discharge. It helps reduce swelling and promotes healing in the perineal area. Ice packs (option
D) are typically used immediately after delivery to provide pain relief. Promethazine (option
A) and aspirin (option
B) are not indicated for managing discomfort associated with an episiotomy. Promethazine is an antihistamine, and aspirin is a nonsteroidal anti-inflammatory drug, both of which are not commonly used for this purpose.