Download NCLEX-PN 3000 Questions with Answers and Rationaleslatest version.pdf and more Exams Nursing in PDF only on Docsity!
NCLEX-PN 3000 Questions with Answers
and Rationaleslatest version
The parent of a preschooler with chickenpox asks the nurse about measures to make the child comfortable. The nurse instructs the parent to avoid administering aspirin or any other product that contains salicylates. When given to children with chickenpox, aspirin has been linked to which disorder?
- Guillain-Barré syndrome
- Rheumatic fever
- Reye's syndrome
- Scarlet fever - Correct Answer: 3 RATIONALES: Research shows a correlation between the use of aspirin during chickenpox and the development of Reye's syndrome (a disorder characterized by brain
and liver toxicity). Therefore, the nurse should instruct the parents to avoid administering aspirin or other products that contain salicylates and to consult the physician or pharmacist before administering any medication to a child with chickenpox. No research has found a link between aspirin use, chickenpox, and the development of Guillain-Barré syndrome, rheumatic fever, or scarlet fever. A client is to have an epidural block to relieve labor pain. The nurse anticipates that the anesthesiologist will inject the anesthetic agent into the:
- subarachnoid space.
- area between the subarachnoid space and the dura mater.
- area between the dura mater and the ligamentum flavum.
- ligamentum flavum. - Correct Answer: 3 RATIONALES: For an epidural block, the nurse should anticipate that the anesthesiologist will inject a local anesthetic agent into the epidural space, located between the dura mater and the ligamentum flavum in the lumbar region of the spinal
- Moisten the area around the wound with normal saline after the irrigation.
- Apply a wet-to-dry dressing to the wound after the irrigation.
- Rapidly instill a stream of irrigating solution into the wound. - Correct Answer: 1 RATIONALES: To wash away tissue debris and drainage effectively, the nurse should irrigate the wound until the solution becomes clear or all of the solution has been used. After the irrigation, the nurse should dry the area around the wound; moistening it promotes microorganism growth and skin irritation. When the area is dry, the nurse should apply a sterile dressing, rather than awet-to-dry dressing. The nurse always should instill the irrigating solution gently; rapid or forceful instillation can damage tissues. As an adolescent is receiving care, he's inadvertently injured with a warm compress. The nurse completes an incident report based on the knowledge that identification of which of the following is a goal of the report?
- To reprimand the involved staff members for their actions
- To identify the learning needs of staff to prevent incident recurrences
- To reprimand the nurse-manager responsible for the unit
- To hold people accountable for their actions - Correct Answer: 2 RATIONALES: The purpose of an incident report is threefold: to identify ways to prevent incident recurrences, to identify patterns of care problems, and to identify facts surrounding each incident. Incident reports aren't used to hold people accountable for their actions, to punish those involved in the incident, or to punish the nurse-manager responsible for the unit. As a client progresses through pregnancy, she develops constipation. What is the primary cause of this problem during pregnancy?
- Decreased appetite
- Inadequate fluid intake
- Substituting an oral antidiabetic agent for insulin - Correct Answer: 2 RATIONALES: During an adolescent growth spurt, a regimen of multiple insulin doses achieves better control of the blood glucose level because it more closely simulates endogenous insulin release. A single daily dose of insulin wouldn't control this client's blood glucose level as effectively. Limiting dietary fat intake wouldn't help the body use glucose at the cellular level. An adolescent with type 1 diabetes mellitus doesn't produce insulin and therefore can't receive an oral antidiabetic agent instead of insulin. A client is admitted to the health care facility with bowel obstruction secondary to colon cancer. The nurse obtains a health history, measures vital signs, and auscultates for bowel sounds. Which step of the nursing process is the nurse performing?
- Planning
- Data collection
- Evaluation
- Implementation - Correct Answer: 2 RATIONALES: During the data collection step of the nursing process, the nurse obtains the client's health history, measures vital signs, and performs a physical examination to gather data for use in formulating the nursing diagnoses. During the planning step, the nurse designs methods to help resolve client problems and meet client needs. During evaluation, the nurse determines the effectiveness of nursing interventions in achieving client goals. During implementation, the nurse takes actions to meet the client's needs. The physician prescribes meperidine (Demerol), 1.1 mg/kg I.M., for a 16-month-old child who has just had abdominal surgery. When administering this drug, the nurse should use a needle of which size?
- 18G
- 20G
- 23G
RATIONALES: Neonates who are hypothermic typically develop bradycardia. Hypoglycemia, not hyperglycemia, and metabolic acidosis, not metabolic alkalosis, are also seen in neonates with hypothermia. Neonates typically don't shiver. Initial client assessment information includes blood pressure 160/110 mm Hg, pulse 88 beats/minute, respiratory rate 22 breaths/minute, and reflexes +3/+4 with 2 beat clonus. Urine specimen reveals +3 protein, negative sugar and ketones. Based on these findings, the nurse would expect the client to have which complaints?
- Headache, blurred vision, and facial and extremity swelling
- Abdominal pain, urinary frequency, and pedal edema
- Diaphoresis, nystagmus, and dizziness
- Lethargy, chest pain, and shortness of breath - Correct Answer: 1 RATIONALES: The client is exhibiting signs of preeclampsia. In addition to hypertension and hyperreflexia, most preeclamptic clients have edema. Headache and blurred vision are indications of the effects of the hypertension. Abdominal pain, urinary frequency,
diaphoresis, nystagmus, dizziness, lethargy, chest pain, and shortness of breath are inconsistent with a diagnosis of preeclampsia. The nurse is performing a baseline assessment of a client's skin integrity. Which of the following is a key assessment parameter?
- Family history of pressure ulcers
- Presence of existing pressure ulcers
- Potential areas of pressure ulcer development
- Overall risk of developing pressure ulcers - Correct Answer: 4 RATIONALES: When assessing skin integrity, the overall risk potential for developing pressure ulcers takes priority. Overall risk encompasses existing pressure ulcers as well as potential areas for development of pressure ulcers. Family history isn't important when assessing skin integrity.
A geriatric client with Alzheimer's disease has been living with his grown child's family for the last 6 months. He wanders at night and needs help with activities of daily living. Which statement by his child suggests that the family is successfully adjusting to this living arrangement?
- "It's difficult dealing with Dad. It's a thankless job."
- "We had no idea this would be so difficult. It's our cross to bear."
- "Dad really seems to be making progress. We're hoping he'll be able to move back into his house soon."
- "Dad has presented many challenges. We have alarms on all the outside doors now. Respite care gives us a break." - Correct Answer: 4 RATIONALES: This statement demonstrates a realistic understanding of the client's disorder and effective family coping with the challenges it presents. Options 1 and 2 indicate that the family is having difficulty adjusting. Option 3 suggests that the family is in denial or has an unrealistic view of the prognosis for a client with Alzheimer's disease.
The nurse is assessing an elderly client. When performing the assessment, the nurse should consider that one normal age-related change is:
- cloudy vision.
- incontinence.
- diminished reflexes.
- tremors. - Correct Answer: 3 RATIONALES: Degenerative changes can lead to decreased reflexes, which is a normal result of aging. Cloudy vision, incontinence, and tremors may be signs and symptoms of underlying pathology and shouldn't be considered normal results of aging. An agitated, confused client arrives in the emergency department. The client's history includes type 1 diabetes, hypertension, andangina pectoris. Assessment reveals pallor, diaphoresis, headache, and intense hunger. A stat blood glucose sample measures 42
dyspnea. He stopped working and rested, and the pain subsided. At noon, the pain returned. At 1:30 p.m., his wife took him to the emergency department. Around 2 p.m., the emergency department physician diagnoses an anterior myocardial infarction (MI). The nurse should anticipate which immediate order by the physician?
- Lidocaine administration
- Cardiac stress test
- Serial liver enzyme testing
- Tissue plasminogen activator (tPA) - Correct Answer: 4 RATIONALES: If 6 hours or less have passed since the onset of symptoms related to MI, thrombolytic therapy is indicated. (The client's chest pain began 4 hours before diagnosis.) The preferred choice is tPA. The client doesn't exhibit symptoms that indicate the use of lidocaine. Stress testing shouldn't be performed during the acute phase of an MI, but it may be ordered before discharge. Serial cardiac biomarkers, not serial liver enzymes, would be ordered for this client.
A nurse's neighbor complains of severe right flank pain. She explains that it began during the night, but she was able to take acetaminophen (Tylenol) and return to bed. When she awoke, the pain increased in intensity. How should the nurse intervene?
- Explain that she can't give medical advice.
- Inform the neighbor that she might require surgery.
- Advise the neighbor to seek medical attention.
- Tell the neighbor that she'll be fine because she was able to get through the night. - Correct Answer: 3 RATIONALES: The nurse should advise the neighbor to seek medical attention. Explaining that she can't give medical advice might cause a delay in treatment. It's beyond the nurse's scope of practice to suggest that the neighbor might need surgery. Telling the neighbor she'll be fine might also delay treatment, and it isn't a professional response.
fluphenazine. Tardive dyskinesia is a possible adverse reaction and should be reported immediately. One day after being admitted with bipolar disorder, a client becomes verbally aggressive during a group therapy session. Which response by the nurse would be therapeutic?
- "You're behaving in an unacceptable manner, and you need to control yourself."
- "If you continue to talk like that, no one will want to be around you."
- "You're disturbing the other clients. I'll walk with you around the patio to help you release some of your energy."
- "You're scaring everyone in the group. Leave the room immediately." - Correct Answer: 3 RATIONALES: This response shows that the nurse finds the client's behavior unacceptable, yet still regards the client as worthy of help. The other options give the
false impression that the client is in control of the behavior; the client hasn't been in treatment long enough to control the behavior. A client comes to the emergency department complaining of headache, malaise, chills, fever, and a stiff neck. Vital sign assessment reveals a temperature elevation, increased heart and respiratory rates, and normal blood pressure. On physical examination, the nurse notes confusion, a petechial rash, nuchal rigidity, Brudzinski's sign, and Kernig's sign. What does Brudzinski's sign indicate?
- Increased intracranial pressure (ICP)
- Cerebral edema
- Low cerebrospinal fluid (CSF) pressure
- Meningeal irritation - Correct Answer: 4 RATIONALES: Brudzinski's sign indicates meningeal irritation, as in meningitis. Other signs of meningeal irritation include nuchal rigidity and Kernig's sign. Brudzinski's sign doesn't indicate increased ICP, cerebral edema, or low CSF pressure.
