NCLEX PN 2023 Quizlet

NCLEX PN 2023 Quizlet Related

Review NCLEX PN 2023 Quizlet related questions and content

Which of the following is an inappropriate item to include in planning care for a severely neutropenic client?

  • A. Transfuse neutrophils (granulocytes) to prevent infection.
  • B. Exclude raw vegetables from the diet.
  • C. Avoid administering rectal suppositories.
  • D. Prohibit vases of fresh flowers and plants in the client's room.
Correct Answer: A

Rationale: The correct answer is to transfuse neutrophils (granulocytes) to prevent infection. Granulocyte transfusion is not routinely indicated to prevent infection in neutropenic clients. While neutrophils are essential in fighting infections and are beneficial in selected populations of infected, severely granulocytopenic clients who do not respond to antibiotics and are expected to experience prolonged suppression of granulocyte production, routine granulocyte transfusion is not recommended. Choices B, C, and D are appropriate interventions for a severely neutropenic client. Prohibiting fresh flowers and plants helps reduce the risk of exposure to environmental pathogens. Avoiding rectal suppositories minimizes the risk of introducing harmful bacteria. Excluding raw vegetables from the diet reduces the likelihood of foodborne infections.

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When a client informs the nurse that he is experiencing hypoglycemia, the nurse provides immediate intervention by providing:

  • A. one commercially prepared glucose tablet
  • B. two hard candies
  • C. 4-6 ounces of fruit juice
  • D. 2-3 teaspoons of honey
Correct Answer: D

Rationale: The correct immediate intervention for hypoglycemia is to provide 10-15 grams of fast-acting simple carbohydrates orally if the client is conscious and able to swallow. This can be achieved by giving 2-3 teaspoons of honey. Honey is a quick source of simple sugars that can rapidly raise blood glucose levels. Commercially prepared glucose tablets or 4-6 ounces of fruit juice are also appropriate options. However, adding sugar to fruit juice is unnecessary as the natural fruit sugar in juice already provides enough simple carbohydrates to raise blood glucose levels. Hard candies are not the best choice for immediate intervention in hypoglycemia as they may not provide a sufficient amount of fast-acting carbohydrates needed to raise blood sugar levels quickly.

For a client with suspected appendicitis, in which quadrant should the nurse expect to find abdominal tenderness?

  • A. upper right
  • B. upper left
  • C. lower right
  • D. lower left
Correct Answer: C

Rationale: The correct answer is C: lower right. Abdominal tenderness in the lower-right quadrant is a classic sign of appendicitis. The appendix is located in the lower right abdomen, so inflammation of the appendix typically causes tenderness in this specific area. Choices A, B, and D are incorrect because tenderness in the upper right, upper left, and lower left quadrants, respectively, is not typical in appendicitis cases. Therefore, the nurse should focus on assessing the lower right quadrant for tenderness when suspecting appendicitis.

For a client with suspected appendicitis, where should the nurse expect to find abdominal tenderness?

  • A. upper right
  • B. upper left
  • C. lower right
  • D. lower left
Correct Answer: C

Rationale: The correct answer is C: lower right. Abdominal tenderness in the lower-right quadrant is a classic symptom of appendicitis. This tenderness is known as McBurney's point, which is located in the lower-right quadrant of the abdomen. Choices A, B, and D are incorrect because the tenderness associated with appendicitis is typically localized to the lower-right quadrant.

Which of the following terms refers to soft tissue injury caused by blunt force?

  • A. contusion
  • B. strain
  • C. sprain
  • D. dislocation
Correct Answer: A

Rationale: A contusion is a soft tissue injury caused by blunt force. It is an injury that does not break the skin, caused by a blow, and characterized by swelling, discoloration, and pain. The immediate application of cold might limit the development of a contusion. A strain is a muscle pull from overuse, overstretching, or excessive stress. A sprain is caused by a wrenching or twisting motion. A dislocation is a condition where the articular surfaces of the bones forming a joint are no longer in anatomical contact. Therefore, the correct answer is 'contusion' as it specifically relates to soft tissue injury caused by blunt force.

Which of the following nursing diagnoses is most appropriate for the client experiencing acute pancreatitis?

  • A. Confusion
  • B. Latex Allergy
  • C. Acute Pain
  • D. Constipation
Correct Answer: C

Rationale: Acute Pain is the most appropriate nursing diagnosis for a client experiencing acute pancreatitis because it is a common symptom associated with this condition. Pancreatitis often presents with severe abdominal pain that may radiate to the back. Confusion, Latex Allergy, and Constipation are not typically associated with acute pancreatitis. Confusion may occur in severe cases of pancreatitis with complications, but acute pain is the priority nursing diagnosis due to its prevalence and impact on the client's well-being.

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