Free NCLEX PN 2020 / 2021 121th Edition

Free NCLEX PN 2020 / 2021 121th Edition

1. A client with a prior history of suicide attempts is admitted to the mental health unit. A diagnosis of depression has been made. A therapist who was working with the client in an outpatient clinic calls the nurse and reports that the client was having severe suicidal thoughts. Keeping this information in mind, the nurse focuses the initial data collection of the client on:

A. The presence of existing suicidal thoughts
B. The client’s interaction with peers
C. Food intake for past 24 hours
D. The past treatment regimen

Answer: A. The presence of existing suicidal thoughts

Rationale: The most critical information from the therapist’s report is that the client was having severe suicidal thoughts; therefore the nurse needs further information about existing thoughts of suicide so that the treatment plan may be as appropriate as possible. The nurse and the health care facility must make sure that the client is safe. The other items should be assessed; however, data collection related to the potential for suicide is most important.

Test-Taking Strategy: Use the process of elimination. Note the relationship between “severe suicidal thoughts” in the question and in the correct option. Additionally, option 1 is the priority. Review care to the suicidal client if you had difficulty with this question.

Level of Cognitive Ability: Analysis
Client Needs: Physiological 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, p. 288.

2. A nurse caring for a client at home arrives at the client’s home and finds the client in the bedroom, unconscious, with a pill bottle in hand. The pill bottle contains the selective serotonin reuptake inhibitor, sertraline (Zoloft). Which of the following would the nurse check first?

A. Blood pressure
B. Respirations
C. Pulse
D. Urinary output

Answer: B. Respirations

Rationale: In an emergency situation, the nurse should determine breathlessness first, then pulselessness. Blood pressure would be checked after these parameters were determined. Urinary output is also important, but not the priority at this time.

Test-Taking Strategy: Use the ABCs—airway, breathing, and circulation—as the guide for answering this question. Respirations specifically relate to breathing and airway. Review emergency care to the client with an overdose of medication if you had difficulty with this question.

Level of Cognitive Ability: Application
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Delegating/Prioritizing
Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders,
pp. 2052-2056.

3. A client is scheduled for a right femoral-popliteal bypass graft. The nurse reviews the plan of care for the client and notes that the client has a nursing diagnosis of ineffective tissue perfusion. The nurse takes which action before surgery to address this nursing diagnosis?

A. Completes a preoperative checklist
B. Marks the location of the pedal pulses on the right leg
C. Has the client void before surgery
D. Checks the results of any baseline coagulation studies

Answer: B. Marks the location of the pedal pulses on the right leg

Rationale: A nursing diagnosis of ineffective tissue perfusion in the client scheduled for femoral-popliteal bypass grafting is likely to indicate the presence of diminished peripheral pulses. It is important to mark the location of any pulses that are palpated or auscultated. This provides a baseline for comparison in the postoperative period. The other options are part of routine preoperative care.

Test-Taking Strategy: Use the process of elimination noting the key words to address this nursing diagnosis. In this case, each of the incorrect options is an action that is part of routine preoperative care and is not specific to this nursing diagnosis. Note the relationship between “ineffective tissue perfusion” in the question and “pedal pulses” in the correct option. Review care to the client scheduled for a femoral-popliteal bypass graft 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/Cardiovascular
Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 338.

4. A nurse is positioning a client for pericardiocentesis to treat cardiac tamponade. The nurse positions the client:

A. Lying on the left side with a pillow under the chest wall
B. Lying on the right side with a pillow under the head
C. Supine with the head of bed elevated at a 45- to 60-degree angle
D. Supine with slight Trendelenburg’s position

Answer: C. Supine with the head of bed elevated at a 45- to 60-degree angle

Rationale: The client undergoing pericardiocentesis is positioned supine with the head of bed elevated to a 45- to 60-degree angle. This places the heart in close proximity to the chest wall for easier insertion of the needle into the pericardial sac. Options 1, 2, and 4 are incorrect positions.

Test-Taking Strategy: Use the process of elimination. If you are uncertain how to proceed with this question, imagine each of the positions described. Evaluate how the heart is sitting in the chest with each position and how easily the pericardial sac could be accessed with a needle. This should help you eliminate the incorrect options. Review this procedure 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/Cardiovascular
Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed.). Philadelphia: W.B. Saunders, p. 860.

Read also:

• Free NCLEX Practice Tests & Sample Questions 2020 / 2021 120th Edition
• NCLEX Questions and Answers pdf 119th Edition
• NCLEX PN Questions Bank 2020 / 2021 118th Edition

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