Download NCLEX-PN Practice Questions for 2024-2025: Nursing Fundamentals and Patient Care and more Exams Nursing in PDF only on Docsity!
NCLEX-PN QUESTIONS FOR 2024-2025 WITH CORRECT ANSWERS
"The physician prescribes penicillin potassium oral suspension 56 mg/kg/day in four divided doses for a client with anorexia nervosa who weighs 25 kg. The medication dispensed by the pharmacy contains a dosage strength of 125 mg/5 ml. How many milliliters of solution should the
nurse administer with each dose? - CORRECT ANSWER : 14
RATIONALES: To determine the total daily dosage, set up the following proportion: 25 kg/X = 1 kg/56 mg X = 1,400 mg. Next, divide the daily dosage by four doses to determine the dose to administer every 6 hours: X = 1,400 mg/4 doses X = 350 mg/dose. The adolescent should receive 350 mg every 6 hours. Lastly, calculate the volume to give for each dose by setting up this proportion: X/350 mg = 5 ml/125 mg X = 14 ml." "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.
4. 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 column. When administering a spinal block, the anesthesiologist injects the anesthetic agent into the subarachnoid space. The ligamentum flavum and the area between the subarachnoid space and the dura mater are inappropriate injection sites." "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
4. 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." "An adolescent with type 1 diabetes mellitus is experiencing a growth spurt. Which treatment approach would be most effective for this client?
4. 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
4. 27G - CORRECT ANSWER : 3
RATIONALES: For an infant, the nurse should use a needle with the smallest appropriate gauge for the medication to be given. For an I.M. injection of meperidine, a 25G to 22G needle is appropriate."
"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
4. 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 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."
4. 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." "A 43-year-old man was transferring a load of firewood from his front driveway to his backyard woodpile at 10 a.m. when he experienced a heaviness in his chest and 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
4. 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.
4. 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." "A client has a history of chronic undifferentiated schizophrenia. Because she has a history of noncompliance with antipsychotic therapy, she'll receive fluphenazine decanoate (Prolixin Decanoate) injections every 4 weeks. Before discharge, what should the nurse include in her teaching plan?
- Asking the physician for droperidol (Inapsine) to control any extrapyramidal symptoms that occur
4. "You're scaring everyone in the group. Leave the room immediately." - CORRECT ANSWER :
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." "During a routine examination, the nurse notes that the client seems unusually anxious. Anxiety can affect the genitourinary system by:
- slowing the glomerular filtration rate.
- increasing sodium resorption.
- decreasing potassium excretion.
4. stimulating or hindering micturition. - CORRECT ANSWER : 4
RATIONALES: Anxiety may stimulate or hinder micturition. Its most noticeable effect is to cause frequent voiding and urinary urgency. However, when anxiety leads to generalized muscle tension, it may hinder urination because the perineal muscles must relax to complete micturition. Anxiety doesn't slow the glomerular filtration rate, increase sodium resorption, or decrease potassium excretion." "The nurse is advising a mother about foods to avoid to prevent choking in her toddler. Which foods should she include in her instruction?
- Small pieces of banana
- Large, round chunks of meat such as hot dog
- Cooked vegetables such as lima beans and corn
4. Frozen desserts such as ice cream - CORRECT ANSWER : 2
RATIONALES: The nurse should advise the mother to avoid giving her child large, round chunks of meat such as hot dog. The mother can safely give the toddler small pieces of banana; cooked vegetables, such as lima beans and corn; and frozen desserts such as ice cream." "A client with a history of Addison's disease and flulike symptoms accompanied by nausea and vomiting over the past week is brought to the facility. The client's wife reports that she noticed that he acted confused and was extremely weak when he woke up in the morning. The client's blood pressure is 90/58 mm Hg, his pulse is 116 beats/minute, and his temperature is 101° F (38.3° C). A diagnosis of acute adrenal insufficiency is made. Which of the following would the nurse expect to administer by I.V. infusion?
- Insulin
- Hydrocortisone
should be applied at 7:30 a.m. Applying EMLA at 6:30 a.m. is too early. The other time options are too late for the local anesthetic to be effective." "Which nursing action is essential when providing continuous enteral feeding?
- Elevating the head of the bed at least 30 degrees
- Positioning the client on the left side
- Warming the formula before administering it
4. Hanging a full day's worth of formula at one time - CORRECT ANSWER : 1
RATIONALES: Elevating the head of the bed at least 30 degrees during enteral feeding minimizes the risk of aspiration and allows the formula to flow into the client's intestines. When such elevation is contraindicated, the client should be positioned on the right side. The nurse should give enteral feedings at room temperature to minimize GI distress. To limit microbial growth, the nurse should hang only the amount of formula that can be infused in 8 hours." "The physician prescribes furosemide (Lasix), 2 mg/kg P.O., as a one-time dose for an infant with fluid overload. The infant's documented weight is 14 lb. The oral solution contains 10 mg/ml. How
many milliliters of solution should the nurse administer? - CORRECT ANSWER : 1.
RATIONALES: To perform the dosage calculation, first convert the infant's weight from pounds to kilograms by setting up the following proportion: 2.2 lb/1 kg = 14 lb/X X = 6.4 kg. Then perform the following calculation to determine the total dose prescribed: 2 mg/kg = X/6.4 kg
X = 12.8 mg. Then set up the following proportion to determine the volume of medication to administer: 10 mg/ml = 12.8 mg/X X = 1.3 ml." "For a client with Graves' disease, which nursing intervention promotes comfort?
- Restricting intake of oral fluids
- Placing extra blankets on the client's bed
- Limiting intake of high-carbohydrate foods
4. Maintaining room temperature in the low-normal range - CORRECT ANSWER : 4
RATIONALES: Graves' disease causes signs and symptoms of hypermetabolism, such as heat intolerance, diaphoresis, excessive thirst and appetite, and weight loss. To reduce heat intolerance and diaphoresis, the nurse should keep the client's room temperature in the low- normal range. To replace fluids lost via diaphoresis, the nurse should encourage, not restrict, intake of oral fluids. Placing extra blankets on the bed of a client with heat intolerance would cause discomfort. To provide needed energy and calories, the nurse should encourage the client to eat high-carbohydrate foods." "A client is admitted with a diagnosis of delusions of grandeur. This diagnosis reflects a belief that he is:
- highly important or famous.
RATIONALES: During a seizure, the nurse's first priority is to protect the child from injury. To prevent injury caused by uncontrolled movements, the nurse must remove objects from the child's surroundings and pad objects that can't be removed. Restraining the child or placing an object in the child's mouth during a seizure may cause injury. Once the seizure stops, the nurse should check for breathing and, if indicated, initiate rescue breathing." "A man at a pizza parlor verbally confronts the waiter for lack of attentiveness. Later, in the back room, the waiter spits on the man's pizza. This is an example of a behavior typical of which disorder?
- Obsessive-compulsive
- Narcissistic
- Passive-aggressive
4. Dependent - CORRECT ANSWER : 3
RATIONALES: This is an example of a negative attitude and passive-aggressive behavior in response to demands for adequate performance. People with this disorder won't confront or discuss issues with others but will go to great lengths to "get even." Obsessive-compulsive disorder involves rituals or rules that interfere with normal functioning. A person with a narcissistic personality has an exaggerated sense of self-worth. A person with a dependent personality is submissive and frequently apologizes and backs down when confronted." "A client with end-stage acquired immunodeficiency syndrome (AIDS) has profound manifestations of Cryptosporidium infectioncaused by the protozoa. In planning the client's care, the nurse should focus on his need for:
- pain management.
- fluid replacement.
- antiretroviral therapy.
4. high-calorie nutrition. - CORRECT ANSWER : 2
RATIONALES: The protozoal enteric infection caused by Cryptosporidium results in profuse watery diarrhea. Because diarrhea will lead to dehydration, the nurse should focus on fluid replacement. Pain management is also a concern in the care of a client with AIDS. However, with Cryptosporidium, the main concern is hydration. Antiretroviral therapy is most useful when a client with human immunodeficiency virus (HIV) doesn't have opportunistic infections. With the wasting associated with AIDS, high-calorie nutrition is important but with Cryptosporidium- related diarrhea, hydration takes precedence." "Following a small-bowel resection, a client develops fever and anemia. The surface surrounding the surgical wound is warm to the touch and necrotizing fasciitis is suspected. Another manifestation that would most suggest necrotizing fasciitis is:
- erythema.
- leukocytosis.
peripheral nerve on the trunk of the body and red, nodular skin lesions. Fever and malaise typically accompany these findings. Diarrhea doesn't commonly occur with shingles." "A newly hired licensed practical nurse (LPN) is helping the charge nurse admit a client. The charge nurse asks the LPN if she understands the facility's rules of ethical conduct. Which statement by the LPN indicates the need for further teaching?
- "I make sure that I do everything in my client's best interest."
- "I maintain client confidentiality at all times."
- "I always support the Patient's Bill of Rights."
4. "I don't discuss advance directives unless the client initiates the conversation." - CORRECT
ANSWER : 4
RATIONALES: The law mandates that health care agencies ask all clients if they have an advance directive. Therefore, the LPN must address this question regardless of whether the client initiates a conversation about it. Nurses must always act in the best interest of their clients, maintain confidentiality, and support the Patient's Bill of Rights." "Which safety device is most restrictive for a client with dementia?
- Walker
- Childproof locks on cabinets and doors
- Electronic monitoring system
4. Lap tray placed on a wheelchair - CORRECT ANSWER : 4
RATIONALES: The goal of care for clients with dementia is to maintain the highest level of functioning. When restraints must be used, the least restrictive type of restraint possible should be used. A lap tray over a wheelchair severely limits the client's mobility and can cause injury if the client tries to get out of the wheelchair. A walker can be very helpful to clients with dementia as they commonly have unsteady gaits. Childproof locks are helpful in preventing accidental contact with harmful substances. An electronic monitoring system is an effective way of managing a client who wanders." "The nurse is teaching parents how to reduce the spread of impetigo. The nurse should encourage parents to:
- teach children to cover mouths and noses when they sneeze.
- have their children immunized against impetigo.
- teach children the importance of proper hand washing.
4. isolate the child with impetigo from other members of the family. - CORRECT ANSWER : 3
