NCLEX-PN
Quizlet NCLEX PN 2023 Questions
Extract:
Question 1 of 5
Which of the following needs immediate medical attention and emergency intervention? The client who:
Correct Answer: C
Rationale:
Choice C is indicative of a tension pneumothorax, which is considered a medical emergency. The respiratory system is severely compromised, and venous return to the heart is affected. The mediastinal shift is to the unaffected side, indicating a critical situation that requires immediate intervention to prevent further deterioration. This condition can rapidly progress to a life-threatening state, necessitating prompt medical attention.
Choices A, B, and D do not present with life-threatening conditions requiring emergency intervention.
Choice A mentions symptoms of pleurisy, which may be painful but not immediately life-threatening.
Choice B describes symptoms of bronchitis, which may require medical attention but not of an emergent nature.
Choice D reflects a common complaint in asthma but does not suggest an immediate life-threatening situation unless severe respiratory distress is present.
Question 2 of 5
A nurse is returning phone calls in a pediatric clinic. Which of the following reports most requires the nurse's immediate attention and phone call?
Correct Answer: A
Rationale: The correct answer is the 8-year-old boy with vomiting, slower movements, and a history of an atrioventricular shunt placement. This report requires immediate attention because the symptoms could indicate a blocked shunt, which is a serious medical condition needing urgent evaluation and intervention. Slower movements in the context of an atrioventricular shunt history could suggest increased intracranial pressure. The other choices involve less urgent issues: choice B describes post-exercise pain, choice C presents with a low-grade fever and headache that could be due to a mild infection, and choice D reports itching associated with a cast, which is a common issue and less critical compared to a potentially blocked shunt.
Question 3 of 5
During a petit mal seizure in the clinic, what should be the highest priority?
Correct Answer: A
Rationale: During a petit mal seizure, the highest priority is to provide a safe environment free of obstructions in the immediate area. This action aims to prevent injuries to the patient during the seizure. While calling a code or contacting the patient's physician may be necessary at some point, immediate safety measures take precedence. Preventing excessive movement of the extremities is relevant but ensuring a safe environment is crucial to avoid harm during the seizure.
Question 4 of 5
A nurse is teaching a client newly diagnosed with Emphysema about the disease process. Which of the following statements best explains the problems associated with emphysema and could be adapted for use in the nurse's discussion with the client?
Correct Answer: B
Rationale: The correct answer is: 'Larger than normal air spaces and loss of elastic recoil cause air to be trapped in the lung and collapse airways.' Emphysema is a breakdown of the elastin and fiber network of the alveoli where the alveoli enlarge or the walls are destroyed. This alveolar destruction leads to the formation of larger-than-normal air spaces. Emphysema is one of a group of pulmonary diseases of a chronic nature characterized by increased resistance to airflow; the entity is part of chronic obstructive pulmonary disease (COP
D).
Choice A is incorrect because emphysema is not primarily characterized by hyperactivity of the medium-sized bronchi causing wheezing and tightness in the chest.
Choice C is incorrect because vasodilation, congestion, and mucosal edema are not the primary mechanisms involved in emphysema, and they do not directly lead to chronic cough and sputum production.
Choice D is incorrect because emphysema is not related to chloride transport issues and thick viscous mucus production.
Question 5 of 5
Which of the following needs immediate medical attention and emergency intervention? The client who:
Correct Answer: C
Rationale:
Choice C is indicative of a tension pneumothorax, which is considered a medical emergency. The respiratory system is severely compromised, and venous return to the heart is affected. The mediastinal shift is to the unaffected side, indicating a critical situation that requires immediate intervention to prevent further deterioration. This condition can rapidly progress to a life-threatening state, necessitating prompt medical attention.
Choices A, B, and D do not present with life-threatening conditions requiring emergency intervention.
Choice A mentions symptoms of pleurisy, which may be painful but not immediately life-threatening.
Choice B describes symptoms of bronchitis, which may require medical attention but not of an emergent nature.
Choice D reflects a common complaint in asthma but does not suggest an immediate life-threatening situation unless severe respiratory distress is present.