PN1 FINAL-NCLEX QUESTIONS FOR EXAM UPDATED WITH EXPERT RATIONALES LATEST VERSION GUARANTEED PASS

PN1 FINAL -NCLEX QUESTIONS FOR EXAM 1 2023 -2024 UPDATED WITH EXPERT RATIONALES LATEST VERSION GUARANTEED PASS While completing a nursing ass essment, the client states he is 70 years old, has a history of staphylococcus infections, increased intraocular pressure, and blurry vision. The nurse concludes that which item reported by the client is a risk factor for the development of cataracts? 1. History of staphylococcus infections 2. Increased intraocular pressure 3. Stated age of client 4. Long complaint of blurry vision Chapter 27 Answer: 3 Rationale: Age above 65 is a risk factor for cataracts. Double vision, increased intraocular pressure, an d blurry vision are signs of glaucoma. **prior exam question A 92 -year-old client is in the hospital. The client is very hard of hearing, and the nurse needs to do the admission interview. Which action is appropriate for the nurse when assessing the client ? 1. Use a cotton swab to clean cerumen in the client's ear before the interview. 2. Speak louder into the client's ear determined to have better hearing. 3. Lower the pitch of the voice and face the client during the interview. 4. Put new batteries in the hearing aid to ensure proper functioning. Answer: 3 Rationale: Hearing loss, especially of upper -range tones, is common in the elderly. Speaking to the client slowly and in a lower -pitched voice while facing the client is the best means of communication. Cleaning cerumen from the client's ears will not overcome age -related hearing loss. Depending on the level of hearing loss, speaking louder into the ear with the better hearing may still not be an effective action. The question states that the client is ha rd of hearing without reference to a hearing aid; if a hearing aid is used, changing the batteries may not be an effective action. A 72 -year-old client has been in the ICU for the past 2 days. Which intervention would be the most appropriate in decreasing the risk for sensory deprivation? Select all that apply. 1. Remove equipment from the room. 2. Explain procedures and routines to the client upon admission. 3. Provide a clock and calendar in the client's room. 4. Maintain a balance of activity and rest pe riods. 5. Maintain constant conversation when in the client's room Answer: 3, 4 Rationale: Providing the client with a clock and calendar helps the client to be oriented to time and date. These would be meaningful stimuli for the client and decrease the chance for sensory deprivation. Activities and rest periods should be spaced and planned to balance high and low levels of sensory stimuli. It may not be realistic in an ICU to remove equipment from the room. Explaining all procedures and routines would incr ease the risk of overload. Continuous conversation is not therapeutic and could place the client at risk for sensory overload as a different problem The nurse must apply an elastic bandage to support a client's sprained ankle. Which action should the nurse take during this procedure? 1. Moderately stretch the bandage and wrap it from distal extremity to proximal. 2. Wrap the extremity loosely enough to insert two fingers beneath the bandage. 3. Maintain a tight stretch with each wrap of the bandage. 4. Star t proximal to the injury site and work distally. Answer: 1 Rationale: To prevent vascular impairment, proper application of elastic bandages is required. Wrapping distal to proximal is compatible with the flow of venous return. Wrapping the bandage evenly while stretching it moderately ensures that there will be even tension applied to the extremity while not occluding circulation. Wrapping the bandage loosely enough to be able to insert two fingers will not secure the bandage in place or provide adequate s upport for the injury. Excessive tension when applying an elastic bandage would cause circulation to be compromised. Wrapping in a proximal to distal direction would inhibit venous return. All of the following clients appear in the emergency room during on e shift. For which clients should the nurse expect the health care provider to order an antibiotic? Select all that apply 1. Cat bite to the hand of an elderly client 2. Laceration from broken glass in a 6 -year-old client 3. Stab wound in the arm of a 37 -year-old client 4. Closed fracture to the ankle of a 40 -year-old soccer player 5. A wrist sprain in a 17 -year-old who was playing basketball Answer: 1, 2, 3 Rationale: A closed fracture or a sprain has no break in the skin. A cat bite, a laceration, and a s tab wound all impair skin integrity, which could lead to infection, and thus may require prophylactic use of an antibiotic. A client on complete bed rest is at risk for disuse syndrome. The nurse should consider which client goal as appropriate? 1. The cli ent has shorter periods of immobility. 2. The client remains free of contractures in lower extremities. 3. The nurse turns the client every 2 hours. 4. The nurse performs passive range of motion to lower extremities every 4 hours. Answer: 2 Rationale: Disu se syndrome is a result of prolonged immobility. Stating "the client remains free of contractures" describes in active terms the desired outcome for the client. Using "shorter periods of immobility" does not provide a specific expectation or outcome for th e client. Stating that the nurse will turn the client every 2 hours is an interven - tion and not a goal. A goal needs to state a specific expecta - tion or outcome for the client. Stating that the nurse will perform passive range of motion every 4 hours is an inter - vention and not a goal. A goal needs to state a specific expectation or outcome for the client. An adult client who, after being hospitalized 3 days ago, is having trouble sleeping. The nurse also notes some confusion during waking hours. What is the most appropriate nursing diagnosis for this client? 1. Ineffective Health Maintenance 2. Ineffective Individual Coping 3. Disturbed Sensory Perception 4. Disturbed Sleep Pattern Answer: 4 Rationale: The client is in a new environment. Changes in environment bring about uncertainty, and the client may be unable to sleep or may sleep less well than at home. Although the client is confused, there is no other data presented that could be the cause, making disturbed sleep pattern a more appropriate selection than disturbed sensory perception which relates to one of the five senses. Ineffective health maintenance and ineffective individual coping are more global nursing diagnoses, which do not address the cli - ent's specific manifestations of inability to sleep and daytime confusion. An 80 -year-old client has been admitted to the nursing unit with Parkinson's disease. Which of the following activities would be most appropriate in preventing disuse syndrome? 1. Providing for the nutritional needs of the client 2. Promoting weight -bearin g exercises 3. Encouraging 8 glasses of fluid in 24 hours 4. Turning and positioning every 2 hours Answer: 2 Rationale: Weight -bearing exercise is the best approach to preventing disuse syndrome. Disuse syndrome occurs because the stresses of weight bearin g are absent and the bone releases calcium. While nutritional needs of a client with Parkinson's is an appropriate nursing intervention, it does not address the prevention of disuse syndrome. Encouraging fluids is important for the elderly client because t hey become easily dehydrated due to a decreased sense thirst; however, it does not address the prevention of disuse syndrome. Turning and repositioning every 2 hours is an important nursing intervention to prevent skin breakdown; this action does not speci fically address the prevention of disuse syndrome. A client has a pressure ulcer on the left hip. The nursing staff has written a nursing diagnosis of Impaired Skin Integrity with a client goal of "skin heals by 6/12." Prior to June 12, the nurse evaluates progress on reaching this goal. Which statement is the best notation of progress toward the goal? 1. Turned every 2 hours; avoided positioning on left side