NCLEX-PN
NCLEX PN Exam Cram Questions
Extract:
Question 1 of 5
Which of the following lab values would indicate symptomatic AIDS in the medical chart? (T4 cell count per deciliter)
Correct Answer: D
Rationale: A T4 cell count of less than 200 cells per deciliter indicates symptomatic AIDS. This severe depletion of T4 cells signifies advanced HIV infection and a significantly compromised immune system.
Choices A, B, and C are incorrect because T4 cell counts above 2000, above 1000, or below 500 cells per deciliter, respectively, are not indicative of symptomatic AIDS.
Question 2 of 5
Which system is primarily affected by tuberculosis (Mycobacterium)?
Correct Answer: C
Rationale: Tuberculosis, caused by Mycobacterium tuberculosis, primarily affects the respiratory system. This aerobic bacillus thrives in highly oxygenated body sites, such as the lungs, growing ends of bones, and the brain. The bacillus is airborne, making the lungs a common site for infection.
Choices A, B, and D are incorrect as tuberculosis predominantly impacts the respiratory system and rarely involves the stomach, heart, or skin.
Question 3 of 5
A mother brings her 13-month-old child with Down Syndrome to a pediatric clinic reporting muscle weakness and poor movement. The child's reflexes are noted to be diminished. Which action should the nurse take first?
Correct Answer: D
Rationale: In a child with Down Syndrome presenting with muscle weakness and diminished reflexes, an atlanto-axial dislocation is a concern. The priority action is to position the child's neck in a neutral c-spine posture to prevent further injury. This should be done before any movement or manipulation. Contacting the physician should follow to ensure appropriate evaluation and management. Initiating an IV is not indicated unless specifically ordered for a medical reason. Ordering an X-ray for a c-spine work-up should not be the first action as it may involve movement that could exacerbate the condition if an injury is present.
Question 4 of 5
Which of the following situations requires nurse intervention?
Correct Answer: C
Rationale: The correct answer is C. Patient confidentiality must be maintained at all times to respect the patient's privacy and dignity. Disclosing sensitive information like a patient's prognosis in a public setting violates confidentiality and can cause distress. The nurse should intervene in this situation and educate the nursing student about the importance of not discussing confidential patient information in public.
Choices A, B, and D do not involve breaching patient confidentiality and do not require immediate nurse intervention.
Choice A focuses on infection control measures, choice B relates to clinical assessment, and choice D is about the doctor's rounds, which are not urgent matters requiring immediate intervention.
Question 5 of 5
Clomiphene is prescribed for a female client to treat infertility. The nurse is providing information to the client and her spouse about the medication and provides the couple with which information?
Correct Answer: D
Rationale: The correct answer is that multiple births (usually twins) occur in a small percentage (8% - 10%) of clomiphene-facilitated pregnancies. The couple should be informed about this potential outcome. Clomiphene is available in 50-mg tablets for oral use; there is no intravenous form of the medication. Breast engorgement is a common side effect of clomiphene that typically resolves after discontinuation of the medication. Ovulation usually happens 5 to 10 days after the last dose of clomiphene, and the couple is advised to engage in coitus at least every other day during this time.
Therefore, choices A, B, and C are incorrect as they do not provide accurate information regarding clomiphene treatment for infertility.