NCLEX-PN Exam Questions - Part 125

1. A thirty-seven year-old female in room 307 has a diagnosis of acquired immune deficiency syndrome (AIDS). Which of the following situations requires nurse intervention?

A) A certified nursing assistant states, 'The patient in 307 is not wearing gloves shaving her legs.'
B) A nursing assistant at the nursing station states, 'The patient in 307 has a respiratory rate of 16.'
C) A nursing student in the cafeteria states, 'Dr.Jones told the patient in room 307 that she was going to die.'
D) A certified nursing assistant states, 'Dr. Jones hasn - t made rounds this morning.'



2. A twenty-one year old man suffered a concussion and the MD ordered a MRI. The patient asks, 'Will they allow me to sit up during the MRI?' The correct response by the nurse should be.

A) 'I will have to talk to the doctor about letting you sit upright during the test.'
B) 'You will be positioned in the reverse Trendelenburg position to maximize the view of the brain.'
C) 'The radiologist will let you know.'
D) 'You will have to lie down on your back during the test.'



3. A fifty-five year-old man suffered a left frontal lobe CVA. The patients family is not present in the room. Which of the following should the nurse watch most closely for?

A) Changes in emotion and behavior
B) Monitor loss of hearing
C) Observe appetite and vision deficits
D) Changes in facial muscle control



4. A nurse working in a pediatric clinic observes bruises on the body of a four year-old boy. The parents report the boy fell riding his bike. The bruises are located on his posterior chest wall and gluteal region. The nurse should:

A) Suggest a script for counseling for the family to the doctor on duty.
B) Recommend a warm bath for the boy to decrease healing time.
C) Notify the case manager in the clinic about possible child abuse concerns.
D) Recommend ROM to the patient - s spine to decrease healing time.



5. A central venous pressure reading of 11cm/H(2)0 of an IV of normal saline is determined by the nurse caring for the patient. The patient has a diagnosis of pericarditis. Which of the following is the most applicable:

A) The patient has a condition of hypovolemia.
B) Not enough fluid has been given to the patient.
C) Pericarditis may cause pressures greater than 10cm/H(2)0 with testing of CVP.
D) The patient may have a condition of arteriosclerosis.