NCLEX-PN RATIONALE EXAM 2024 QUESTIONS WITH 100% CORRECT ANSWERS 2024

NCLEX-PN RATIONALE EXAM 2024 QUESTIONS WITH 100% CORRECT ANSWERS 2024 When preparing a client for a pericardiocentesis, how does the nurse position the client? - ANSWERS 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: - ANSWERS 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? - ANSWERS 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: - ANSWERS 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? - ANSWERS 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: - ANSWERS 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? - ANSWERS "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? - ANSWERS 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? - ANSWERS 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? - ANSWERS Avoiding exposure to either very hot or very cold weather Rationale: The client should avoid extreme hot or cold temperatures to avoid placing undue stress on the cardiovascular system. The client should space activities throughout the day rather than save them for the end of the day when the client is more fatigued. The client should eat smaller meals so less blood flow is diverted for the work of digestion. Exercise is important, but the client should keep most items stored at heart level, to prevent straining and increased intrathoracic pressure, which can decrease cardiac output.