NCLEX-PN LATEST 2024 -2025 COMPLETE EXAM

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NCLEX-PN LATEST 2024 -2025 COMPLETE EXAM/

ACTUAL EXAM QUESTIONS WITH CORRECT

DETAILED ANSWERS (VERIFIED ANSWERS)

AGRADE ASSURED!!

A client with pneumonia is experiencing problems with ventilation as a result of accumulated respiratory secretions. The nurse determines that which of the following accurately indicates effectiveness of the treatments prescribed for this problem – ✓ Arterial blood gases indicate a pH of 7.4, Po2 of 80 mm Hg, Pco2 of 40 mm Hg.

Rationale:

Demonstration of adequate ventilation can only be accurately evaluated when both Po2 and Pco2 levels are known. The other options do not indicate adequate gas exchange.Remember that oxygen saturation index is a measure of the percent of oxygen attached to the available hemoglobin.

A nurse is assisting in caring for a client with a supratentorial lesion. The nurse monitors which of the following as the critical index of central nervous system (CNS) dysfunction?✓ Level of consciousness

Rationale:

Level of consciousness is the most critical index of CNS dysfunction. Changes in level of consciousness can indicate clinical improvement or deterioration. Although blood pressure, temperature, and ability to speak may be components of the assessment, the client level of consciousness is the most critical index of CNS dysfunction.

A nurse is preparing a plan of care to monitor for complications in a client who will be returning from the operating room following transsphenoidal resection of a pituitary adenoma. Which of the following does the nurse document in the plan as the priority nursing intervention for this client? – ✓ Monitor urine output. 1 / 3

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Rationale:

The most common complication of surgery on the pituitary gland is temporary diabetes insipidus. This results from deficiency in antidiuretic hormone (ADH) secretion as a result of surgical trauma. The nurse measures the client's urine output to determine whether this complication is occurring. Options 1, 3, and 4 are also components of the plan, but option 2 clearly identifies the priority intervention for this type of surgery.

A nurse is assisting in caring for a client in the telemetry unit who is receiving an intravenous infusion of 1000 mL 5% dextrose with 40 mEq of potassium chloride. Which occurrence observed on the cardiac monitor indicates the presence of hyperkalemia? – ✓ Tall, peaked T waves

Rationale:

The symptoms of hyperkalemia relate to its effect on the myocardial muscle. These include changes noted on the ECG, such as tall, peaked T waves, prolonged P-R interval, widening of the QRS complex, shortening of the Q-T interval, and disappearance of the P wave. Other cardiac symptoms include ventricular dysrhythmias that may lead to cardiac arrest. ST-segment depression is noted in hypokalemia.

A licensed practical nurse (LPN) is assisting in the care of a client who is having central venous pressure (CVP) measurements taken by the registered nurse (RN). The LPN would assist the RN by placing the bed in which of the following positions for the reading?✓ Flat

Rationale:

To obtain a CVP measurement, the head of the bed should be flat in order for the readings to be accurate. The use of the other positions listed would result in false low or false high readings.

An older client with ischemic heart disease has experienced an episode of dizziness and shortness of breath. The nurse reviews the plan of care and notes documentation of decreased cardiac output, dyspnea, and syncopal episodes. The nurse plans to take which important action in the care of the client?✓ Place the client on a cardiac monitor.

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Rationale:

The client with decreased cardiac output should be placed on continuous cardiac monitoring so myocardial perfusion and presence of dysrhythmias can be most accurately assessed. Other cardiovascular data should be collected at least every 2 hours initially.

A nurse is planning to use an external cardiac defibrillator on a client. Which one of the following actions should the nurse perform to check the cardiac rhythm?✓ Applying the adhesive patch electrodes to the skin and moving away from the client

Rationale:

The nurse or rescuer puts two large adhesive patch electrodes on the client's chest in the usual defibrillator position. The nurse stops cardiopulmonary resuscitation and orders anyone near the client to move away and not touch the client. The defibrillator then analyzes the rhythm, which may take up to 30 seconds. The machine then indicates if it is necessary to defibrillate. Although automatic external defibrillation can be done transtelephonically, it is done through the use of patch electrodes (not standard electrocardiographic electrodes) that interact via telephone lines to a base station that controls any actual defibrillation. It is not necessary to hold defibrillator paddles against the client's chest with this device.

A client has undergone a right pneumonectomy. The nurse positioning this client following admission from the postanesthesia care unit avoids placing the client in which harmful position?✓ Right lateral

Rationale:

The client who has a pneumonectomy should not be positioned in the extreme lateral position. This could cause mediastinal shift and compression of remaining lung tissue.The other positions do not pose this risk for the client.

A nurse is caring for a client with pheochromocytoma. The client is scheduled for an adrenalectomy. During the preoperative period, the priority nursing action would be to

monitor the: -

✓ Vital signs

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