Example of NCLEX PN Questions 85th Edition
Example of NCLEX PN Questions 85th Edition
1. A client with a burn injury is scheduled for a heterograft. The nurse is preparing the client for the skin grafting, and the client asks the nurse what “heterograft” means. The appropriate response to the client is:
A. “It is skin from another species.”
B. “It is skin from a cadaver.”
C. “It is skin from the burned client.”
D. “It is skin from a skin bank.”
Answer: A. “It is skin from another species.”
Rationale: Biological dressings are obtained from living or deceased humans (homograft or allograft) or animals (heterograft or xenograft). A heterograft is skin from another species. The most commonly used type of heterograft is pigskin because of its relative compatibility with human skin. A homograft is skin from another human, which is usually obtained from a cadaver and is provided through a skin bank.
Test-Taking Strategy: Use the process of elimination. Note that options 2, 3, and 4 all refer to donor skin from the human species. Option 1, the correct option, identifies skin from a different species. Review the various types of skin grafts if you had difficulty with this question.
Level of Cognitive Ability: Application
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Adult Health/Integumentary
References: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders,
pp. 1459-1460.
Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed.). St. Louis: Mosby, pp. 528-529.
2. A nurse is assisting in caring for a client who sustained a traumatic head injury following a motor vehicle accident. The nurse documents that the client is exhibiting decerebrate posturing. The nurse bases this documentation on which observation?
A. Extension of the extremities and pronation of the arms
B. Flexion of the extremities and pronation of the arms
C. Upper extremity flexion with lower extremity extension
D. Upper extremity extension with lower extremity flexion
Answer: A. Extension of the extremities and pronation of the arms
Rationale: Decerebrate posturing (abnormal extension), which is associated with dysfunction in the brainstem area, consists of extension of the extremities and pronation of the arms. Posturing is a late sign of deterioration in the client’s neurological status and warrants immediate physician notification.
Test-Taking Strategy: Knowledge regarding the findings noted in posturing is required to answer this question. Remember that decerebrate posturing (abnormal extension) consists of extension of the extremities and pronation of the arms. Review this abnormal neurological finding if you had difficulty with this question.
Level of Cognitive Ability: Analysis
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Data Collection
Content Area: Adult Health/Neurological
Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 383.
3. A client with diabetes mellitus calls the clinic nurse to report that the blood glucose level is 150 mg/dl. After obtaining further data from the client, the nurse determines that the client ate lunch approximately 2 hours ago. The nurse would interpret these results to be:
A. Normal
B. Lower than the normal value
C. Slightly higher than the normal value
D. A value that indicates immediate physician notification
Answer: C. Slightly higher than the normal value
Rationale: Normal fasting blood glucose values range from 70 to 120 mg/dl. The 2-hour postprandial blood glucose level should be less than 140 mg/dl. In this situation, the blood glucose value was 150 mg/dl 2 hours after the client ate, which is slightly elevated above normal. This value does not require physician notification.
Test-Taking Strategy: Focus on the data in the question. Noting that the client ate 2 hours before the blood test will direct you to the correct option. If you had difficulty with this question, review normal blood glucose and 2-hour postprandial blood glucose values.
Level of Cognitive Ability: Analysis
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Evaluation
Content Area: Adult Health/Endocrine
Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed.). Philadelphia: W.B. Saunders, p. 599.
4. A client was admitted to a medical unit because the client suddenly experienced total deafness. The client undergoes numerous testing to determine the cause of the deafness. All test results are negative, and there seems to be no organic reason why this client cannot hear. On further review of the client’s record, the nurse notes that the client became deaf after witnessing a murder. Based on this data and the results of the diagnostic tests, the nurse suspects that the client may be experiencing:
A. Psychosis
B. A conversion disorder
C. A dissociative disorder
D. Repression
Answer: B. A conversion disorder
Rationale: A conversion disorder is the alteration or loss of a physical function that cannot be explained by any known pathophysiological mechanism. It is thought to be an expression of a psychological need or conflict. In this scenario, the client witnessed a murder that was so psychologically painful that the client became deaf. Psychosis is a state in which a person’s mental capacity to recognize reality, communicate, and relate to others is impaired, thus interfering with the person’s capacity to deal with life demands. A dissociative disorder is a disturbance or alteration in the normally integrative functions of identity, memory, or consciousness. Repression is a coping mechanism in which unacceptable feelings are kept out of awareness.
Test-Taking Strategy: Knowledge regarding defense mechanisms is required to answer the question. The key to the answer lies in the fact that the client evidences no organic reason to account for the deafness, hence, a conversion disorder. If you had difficulty with this question, review the manifestations associated with a conversion disorder.
Level of Cognitive Ability: Analysis
Client Needs: Psychosocial Integrity
Integrated Process: Nursing Process/Data Collection
Content Area: Mental Health
Reference: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis: Mosby, pp. 229-230.
Source : NCLEX Questions and answer
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