NCLEX PN Exam 2024 | NCLEX PN Actual
Exam Latest Update 2024 Questions and
Correct Answers Rated A+
When preparing a client for a pericardiocentesis, how does the nurse
position the client? -ANSWER-Supine with the head of bed elevated at
a 45- to 60-degree angle
Rationale:
The client undergoing pericardiocentesis is positioned supine with the
head of bed elevated to a 45- to 60-degree angle. This places the
heart in proximity to the chest wall for easier insertion of the needle
into the pericardial sac. The remaining options are incorrect positions
for this procedure.
A client with angina complains that the anginal pain is prolonged and
severe and occurs at the same time each day, most often in the
morning. On further data collection, the nurse notes that the pain
occurs in the absence of precipitating factors. This type of anginal pain
is best described as: -ANSWER-Variant angina
Rationale:
Variant angina, or Prinzmetal's angina, is prolonged and severe and
occurs at the same time each day, most often in the morning. Stable
angina is induced by exercise and relieved by rest or nitroglycerin
tablets. Unstable angina occurs at lower and lower levels of activity or
at rest, is less predictable, and is often a precursor of myocardial
infarction.
,A nurse is caring for a client after thyroidectomy and monitoring for
signs of thyroid storm. The nurse understands that which of the
following is a manifestation associated with this disorder? -ANSWER-
Hypotension
Rationale:
Clinical manifestations associated with thyroid storm include a fever
as high as 106° F (41.1° C), severe tachycardia, profuse diarrhea,
extreme vasodilation, hypotension, atrial fibrillation, hyperreflexia,
abdominal pain, diarrhea, and dehydration. With this disorder, the
client's condition can rapidly progress to coma and cardiovascular
collapse.
A client is admitted to the hospital with a venous stasis leg ulcer. The
nurse inspects the ulcer, expecting to note that the ulcer: -ANSWER-
Has a brownish or "brawny" appearance
Rationale:
Venous leg ulcers, also called stasis ulcers, are typically partial-thick
wounds that extend through the epidermis and portions of the dermis.
The skin of the lower leg is leathery, with a characteristic brownish or
"brawny" appearance from the hemosiderin deposition. The edges of
the ulcer are irregular and the tissue is a ruddy color. The client also
may exhibit peripheral edema.
A client who has had a radical neck dissection begins to hemorrhage
at the incision site. Which action by the nurse would be
contraindicated? -ANSWER-Applying manual pressure over the site
Rationale:
If the client begins to hemorrhage from the surgical site following
radical neck dissection, the nurse elevates the head of the bed to
,maintain airway patency and prevent aspiration. The nurse applies
pressure over the bleeding site and calls the health care provider
immediately.
A nurse checks the water seal chamber of a closed chest drainage
system and notes fluctuations in the chamber. Based on this finding,
the nurse determines that: -ANSWER-The system is functioning as
expected.
Rationale:
Fluctuations in the water seal chamber are normal during inhalation
and exhalation until the lung re-expands and the client no longer
requires chest drainage. If fluctuations are absent, it could indicate an
air leak, kinking, or that the lung has re-expanded.
An ambulatory clinic nurse is interviewing a client who is complaining
of flu-like symptoms. The client suddenly develops chest pain. Which
question would best help the nurse to discriminate pain caused by a
noncardiac problem? -ANSWER-"Does the pain get worse when you
breathe in?"
Rationale:
Chest pain is assessed using the standard pain assessment
parameters, (characteristics, location, intensity, duration, precipitating
and alleviating factors, and associated symptoms). Options 1, 2, and 4
may or may not help determine the origin of pain. Pain of
pleuropulmonary origin usually worsens on inspiration.
A nurse is assisting in checking for Tinel's sign in a client suspected of
having carpal tunnel syndrome (CTS). Which technique would the
nurse expect to be used to elicit this sign? -ANSWER-Percuss the
, medial nerve at the wrist as it enters the carpal tunnel, and monitor for
tingling sensations.
Rationale:
The presence of Tinel's sign is determined by percussing the medial
nerve at the wrist as it enters the carpal tunnel. A tingling sensation
over the distribution of the nerve occurs in CTS. The presence of
Phalen's sign is determined by asking the client to flex the wrist at a
90-degree angle for 1 minute. Numbness and tingling over the
distribution of the median nerve, the palmar surface of the thumb, and
the index and middle fingers suggest CTS. Phalen's sign is also an
indication of CTS.
The nurse is collecting data on a client with chronic airflow limitation
(CAL) and notes that the client has a "barrel chest." The nurse
interprets that this client has which of the following forms of CAL? -
ANSWER-Emphysema
Rationale:
The client with emphysema has hyperinflation of the alveoli and has
flattening of the diaphragm. These lead to increased anteroposterior
diameter, which is referred to as "barrel chest." The client also has
dyspnea with prolonged expiration and has hyperresonant lungs to
percussion.
A nurse is providing instructions to a client with angina pectoris about
measures to reduce recurrence of chest pain. The nurse should stress
to the client the importance of doing which of the following? -
ANSWER-Avoiding exposure to either very hot or very cold weather
Rationale:
Exam Latest Update 2024 Questions and
Correct Answers Rated A+
When preparing a client for a pericardiocentesis, how does the nurse
position the client? -ANSWER-Supine with the head of bed elevated at
a 45- to 60-degree angle
Rationale:
The client undergoing pericardiocentesis is positioned supine with the
head of bed elevated to a 45- to 60-degree angle. This places the
heart in proximity to the chest wall for easier insertion of the needle
into the pericardial sac. The remaining options are incorrect positions
for this procedure.
A client with angina complains that the anginal pain is prolonged and
severe and occurs at the same time each day, most often in the
morning. On further data collection, the nurse notes that the pain
occurs in the absence of precipitating factors. This type of anginal pain
is best described as: -ANSWER-Variant angina
Rationale:
Variant angina, or Prinzmetal's angina, is prolonged and severe and
occurs at the same time each day, most often in the morning. Stable
angina is induced by exercise and relieved by rest or nitroglycerin
tablets. Unstable angina occurs at lower and lower levels of activity or
at rest, is less predictable, and is often a precursor of myocardial
infarction.
,A nurse is caring for a client after thyroidectomy and monitoring for
signs of thyroid storm. The nurse understands that which of the
following is a manifestation associated with this disorder? -ANSWER-
Hypotension
Rationale:
Clinical manifestations associated with thyroid storm include a fever
as high as 106° F (41.1° C), severe tachycardia, profuse diarrhea,
extreme vasodilation, hypotension, atrial fibrillation, hyperreflexia,
abdominal pain, diarrhea, and dehydration. With this disorder, the
client's condition can rapidly progress to coma and cardiovascular
collapse.
A client is admitted to the hospital with a venous stasis leg ulcer. The
nurse inspects the ulcer, expecting to note that the ulcer: -ANSWER-
Has a brownish or "brawny" appearance
Rationale:
Venous leg ulcers, also called stasis ulcers, are typically partial-thick
wounds that extend through the epidermis and portions of the dermis.
The skin of the lower leg is leathery, with a characteristic brownish or
"brawny" appearance from the hemosiderin deposition. The edges of
the ulcer are irregular and the tissue is a ruddy color. The client also
may exhibit peripheral edema.
A client who has had a radical neck dissection begins to hemorrhage
at the incision site. Which action by the nurse would be
contraindicated? -ANSWER-Applying manual pressure over the site
Rationale:
If the client begins to hemorrhage from the surgical site following
radical neck dissection, the nurse elevates the head of the bed to
,maintain airway patency and prevent aspiration. The nurse applies
pressure over the bleeding site and calls the health care provider
immediately.
A nurse checks the water seal chamber of a closed chest drainage
system and notes fluctuations in the chamber. Based on this finding,
the nurse determines that: -ANSWER-The system is functioning as
expected.
Rationale:
Fluctuations in the water seal chamber are normal during inhalation
and exhalation until the lung re-expands and the client no longer
requires chest drainage. If fluctuations are absent, it could indicate an
air leak, kinking, or that the lung has re-expanded.
An ambulatory clinic nurse is interviewing a client who is complaining
of flu-like symptoms. The client suddenly develops chest pain. Which
question would best help the nurse to discriminate pain caused by a
noncardiac problem? -ANSWER-"Does the pain get worse when you
breathe in?"
Rationale:
Chest pain is assessed using the standard pain assessment
parameters, (characteristics, location, intensity, duration, precipitating
and alleviating factors, and associated symptoms). Options 1, 2, and 4
may or may not help determine the origin of pain. Pain of
pleuropulmonary origin usually worsens on inspiration.
A nurse is assisting in checking for Tinel's sign in a client suspected of
having carpal tunnel syndrome (CTS). Which technique would the
nurse expect to be used to elicit this sign? -ANSWER-Percuss the
, medial nerve at the wrist as it enters the carpal tunnel, and monitor for
tingling sensations.
Rationale:
The presence of Tinel's sign is determined by percussing the medial
nerve at the wrist as it enters the carpal tunnel. A tingling sensation
over the distribution of the nerve occurs in CTS. The presence of
Phalen's sign is determined by asking the client to flex the wrist at a
90-degree angle for 1 minute. Numbness and tingling over the
distribution of the median nerve, the palmar surface of the thumb, and
the index and middle fingers suggest CTS. Phalen's sign is also an
indication of CTS.
The nurse is collecting data on a client with chronic airflow limitation
(CAL) and notes that the client has a "barrel chest." The nurse
interprets that this client has which of the following forms of CAL? -
ANSWER-Emphysema
Rationale:
The client with emphysema has hyperinflation of the alveoli and has
flattening of the diaphragm. These lead to increased anteroposterior
diameter, which is referred to as "barrel chest." The client also has
dyspnea with prolonged expiration and has hyperresonant lungs to
percussion.
A nurse is providing instructions to a client with angina pectoris about
measures to reduce recurrence of chest pain. The nurse should stress
to the client the importance of doing which of the following? -
ANSWER-Avoiding exposure to either very hot or very cold weather
Rationale:
