NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2023, Exams of Nursing

Download NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2023 and more Exams Nursing in PDF only on Docsity! NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2023 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? 1. Guillain-Barré syndrome 2. Rheumatic fever 3. 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 client is to have an epidural block to relieve labor pain. The nurse anticipates that the anesthesiologist will inject the anesthetic agent into the: NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2023 1. subarachnoid space. 2. area between the subarachnoid space and the dura mater. 3. 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. 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 NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2023 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? 1. Decreased appetite 2. Inadequate fluid intake 3. Prolonged gastric emptying 4. Reduced intestinal motility ✅Correct Answer: 4 RATIONALES: During pregnancy, hormonal changes and mechanical pressure reduce motility in the small intestine, enhancing water absorption and promoting constipation. Although decreased appetite, inadequate fluid intake, and prolonged gastric emptying may contribute to constipation, they aren't the primary cause. An adolescent with type 1 diabetes mellitus is experiencing a growth spurt. Which treatment approach would be most effective for this client? 1. Administering insulin once per day 2. Administering multiple doses of insulin 3. Limiting dietary fat intake 4. Substituting an oral antidiabetic agent for insulin ✅Correct Answer: 2 NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2023 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? 1. Planning 2. Data collection 3. Evaluation 4. Implementation ✅Correct Answer: 2 NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2023 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? 1. 18G 2. 20G 3. 23G NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2023 4. 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? 1. Family history of pressure ulcers 2. Presence of existing pressure ulcers NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2023 3. Potential areas of pressure ulcer development 4. 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. The nurse is preparing to boost a client up in bed. She instructs the client to use the overbed trapeze. Which risk factor for pressure ulcer development is the nurse reducing by instructing the client to move in this manner? 1. Friction 2. Impaired circulation NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2023 3. Localized pressure 4. Shearing forces ✅Correct Answer: 4 RATIONALES: Using a trapeze reduces shearing forces (opposing forces that cause layers of skin to move over each other, stretching and tearing capillaries and, eventually, resulting in necrosis), which increase the risk of pressure ulcer development. They can occur as clients slide down in bed or when they're pulled up in bed. To reduce shearing forces, the nurse should instruct the client to use an overbed trapeze, place a draw sheet under the client to move the client up in bed, and keep the head of the bed no higher than 30 degrees. The risks of friction, impaired circulation, and localized pressure aren't decreased with trapeze use. 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? NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2023 Assessment reveals pallor, diaphoresis, headache, and intense hunger. A stat blood glucose sample measures 42 mg/dl, and the client is treated for an acute hypoglycemic reaction. After recovery, the nurse teaches the client to treat hypoglycemiaby ingesting: 1. 2 to 5 g of a simple carbohydrate. 2. 10 to 15 g of a simple carbohydrate. 3. 18 to 20 g of a simple carbohydrate. 4. 25 to 30 g of a simple carbohydrate. ✅Correct Answer: 2 RATIONALES: To reverse hypoglycemia, the American Diabetes Association recommends ingesting 10 to 15 g of a simple carbohydrate, such as three to five pieces of hard candy, two to three packets of sugar (4 NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2023 to 6 tsp), or 4 oz of fruit juice. If necessary, this treatment can be repeated in 15 minutes. Ingesting only 2 to 5 g of a simple carbohydrate may not raise the blood glucose level sufficiently. Ingesting more than 15 g may raise it above normal, causing hyperglycemia. 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? 1. Lidocaine administration 2. Cardiac stress test 3. Serial liver enzyme testing NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2023 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? 1. Explain that she can't give medical advice. 2. Inform the neighbor that she might require surgery. NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2023 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? 1. "You're behaving in an unacceptable manner, and you need to control yourself." 2. "If you continue to talk like that, no one will want to be around you." 3. "You're disturbing the other clients. I'll walk with you around the patio to help you release some of your energy." 4. "You're scaring everyone in the group. Leave the room immediately." ✅Correct Answer: 3 NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2023 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? 1. Increased intracranial pressure (ICP) 2. Cerebral edema 3. Low cerebrospinal fluid (CSF) pressure NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2023 4. 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. During a routine examination, the nurse notes that the client seems unusually anxious. Anxiety can affect the genitourinary system by: 1. slowing the glomerular filtration rate. 2. increasing sodium resorption. 3. decreasing potassium excretion. NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2023 2. Hydrocortisone 3. Potassium 4. Hypotonic saline ✅Correct Answer: 2 RATIONALES: Emergency treatment for acute adrenal insufficiency (addisonian crisis) is I.V. infusion of hydrocortisone and saline solution. The client is usually given 100 mg of hydrocortisone in normal saline every 6 hours until his blood pressure returns to normal. Insulin isn't indicated in this situation because adrenal insufficiency is usually associated with hypoglycemia. Potassium isn't indicated because these clients are usually hyperkalemic. The client needs normal — not hypotonic — saline solution. A toddler is diagnosed with a dislocated right shoulder and a simple fracture of the right humerus. Which behavior most stronglysuggests that the child's injuries stem from abuse? 1. Trying to sit up on the stretcher NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2023 2. Trying to move away from the nurse 3. Not answering the nurse's questions 4. Not crying when moved ✅Correct Answer: 4 RATIONALES: Not crying when moved most strongly suggests child abuse. A victim of child abuse typically doesn't complain of pain, even with obvious injuries, for fear of further displeasing the abuser. Trying to sit up on the stretcher is a typical client response. Trying to move away from the nurse indicates fear of strangers, which is normal in a toddler. Difficulty answering the nurse's questions is expected in a toddler because of poorly developed cognitive skills. A client is scheduled for an excretory urography at 10 a.m. An order states to insert a saline lock I.V. device at 9:30 a.m.. The client requests a local NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2023 anesthetic for the I.V. procedure and the physician orders lidocaine- prilocaine cream (EMLA cream). The nurse should apply the cream at: 1. 7:30 a.m. 2. 6:30 a.m. 3. 9 a.m. 4. 9:30 a.m. ✅Correct Answer: 1 RATIONALES: It takes up to 2 hours for lidocaine-prilocaine cream (EMLA cream) reach its maximum effectiveness. Therefore, if the cannulation is scheduled for 9:30 a.m., EMLA cream 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. NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2023 RATIONALES: Common food allergens include berries, peanuts, Brazil nuts, cashews, shellfish, and eggs. Bread, carrots, and oranges rarely cause allergic reactions. 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: 1.3 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? NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2023 1. Restricting intake of oral fluids 2. Placing extra blankets on the client's bed 3. 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 NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2023 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: 1. highly important or famous. 2. being persecuted. 3. connected to events unrelated to himself. 4. responsible for the evil in the world. ✅Correct Answer: 1 RATIONALES: A client with delusions of grandeur has a false belief that he is highly important or famous. A delusion of persecution is a false belief that NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2023 4. It helps the client identify the relationship between his problems and alcohol consumption. ✅Correct Answer: 4 RATIONALES: The purpose of rehabilitative treatment in alcoholism is to help the client identify the relationship between his problems and his alcohol consumption. Rehabilitative treatment promotes abstinence, not limiting or controlling consumption. It isn't intended to help the client identify a new group of friends or understand the effects of alcohol on his body. 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? 1. Obsessive-compulsive 2. Narcissistic 3. Passive-aggressive NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2023 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: 1. pain management. NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2023 2. fluid replacement. 3. 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: NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2023 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? 1. "I make sure that I do everything in my client's best interest." 2. "I maintain client confidentiality at all times." 3. "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 NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2023 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? 1. Walker 2. Childproof locks on cabinets and doors 3. 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 NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2023 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: 1. teach children to cover mouths and noses when they sneeze. 2. have their children immunized against impetigo. 3. teach children the importance of proper hand washing. NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2023 3. Comfort care options 4. Bone marrow transplantation information ✅Correct Answer: 3 RATIONALES: The nurse shouldn't give a positive appraisal of the child's prognosis because doing so gives the parents false hope. The nurse must be honest about the child's prognosis and provide them accurate information about treatment options, which include palliative care, comfort care, and pain management. The physician — not the nurse — should discuss such treatment options as chemotherapy or bone marrow transplantation, if indicated. A client is scheduled for surgery under general anesthesia. The night before surgery, the client tells the nurse, "I can't wait to have breakfast tomorrow." Based on this statement, the nurse should formulate which nursing diagnosis? 1. Deficient knowledge related to food restrictions associated with anesthesia NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2023 2. Fear related to surgery 3. Risk for impaired skin integrity related to upcoming surgery 4. Ineffective coping related to the stress of surgery ✅Correct Answer: 1 RATIONALES: The client's statement reveals a Deficient knowledge related to food restrictions associated with general anesthesia.The other options may be applicable but aren't related to the client's statement. The nurse is caring for a client with skin grafts covering third-degree burns on the arms and legs. During dressing changes, the nurse should be sure to: 1. apply maximum bandages to allow for absorption of drainage. NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2023 2. wrap elastic bandages distally to proximally on dependent areas. 3. wrap elastic bandages on the arms and legs, proximally to distally, to promote venous return. 4. put on sterile gloves only when removing bandages. ✅Correct Answer: 2 RATIONALES: Wrapping elastic bandages on dependent areas limits edema formation and bleeding and promotes graft acceptance. The nurse should wrap the client's arms and legs from the distal to proximal ends and use strict sterile technique throughout the dressing change. Applying maximum bandages should be avoided because bulky dressings limit mobility; instead, the nurse should use enough bandages to absorb wound drainage. Sterile gloves are required throughout all phases of the dressing change to prevent contamination. A client with hyperemesis gravidarum is on a clear liquid diet. The nurse should serve this client: NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2023 occurs during peritoneal dialysis because of the high glucose content of the dialysate; it's readily treatable with sliding-scale insulin. A potassium level of 3.8 mEq/L is an acceptable value. An HCT of 35% is lower than normal. However, in this client, the value isn't abnormally low because of the daily blood samplings. A lower HCT is common in clients with chronic renal failure because of the lack of erythropoietin. The nurse is collecting data on an 8-month-old infant during a wellness checkup. Which of the following is a normal developmental task for an infant this age? 1. Sitting without support 2. Saying two words 3. Feeding himself with a spoon NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2023 4. Playing patty-cake ✅Correct Answer: 1 RATIONALES: According to the Denver Developmental Screening Test, most infants should be able to sit unsupported by age 7 months. A 15- month-old child should be able to say two words. By 17 months, the toddler should be able to feed himself with a spoon. A 10-month-old infant should be able to play patty-cake. The nurse is caring for a client with tuberculosis. Which precautions should the nurse take when providing care for this client? Select all that apply: 1. Wear gloves when handling tissues containing sputum. 2. Wear a face mask at all times. 3. Keep the client in strict isolation. NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2023 4. When the client leaves the room for tests, have all people in contact with him wear a mask. 5. Keep the client's door open to allow fresh air into room and prevent social isolation. 6. Wash hands after direct contact with the client or contaminated articles. ✅Correct Answer: 1,2,6 RATIONALES: The nurse should always wear gloves when handling items contaminated with sputum or body secretions. All staff and visitors must wear face masks when coming in contact with the client in his room; masks must be discarded before leaving the client's room. Hand washing is required after direct contact with the client or contaminated articles. Strict isolation isn't required if the client adheres to special respiratory precautions. The client, not the people in contact with him, must wear a mask when leaving the room for tests. The client should be in a negative- pressure, private room, and the door should remain closed at all times to prevent the spread of infection. A client with moderate pregnancy-induced hypertension (PIH) is a poor candidate for regional anesthesia during labor and delivery. If she were to receive this form of anesthesia, she might experience: NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2023 compresses stimulates the let-down reflex and causes the breasts to fill, which may lead to engorgement. A brassiere supports the breasts but doesn't prevent engorgement. A client with chronic renal failure has a serum potassium level of 6.8 mEq/L. What should the nurse assess first? 1. Blood pressure 2. Respirations 3. Temperature 4. Cardiac rhythm ✅Correct Answer: 4 NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2023 RATIONALES: The nurse should assess the client's cardiac rhythm using electrocardiography because an elevated serum potassium level may lead to a life-threatening cardiac arrhythmia. The client's blood pressure may change, but only as a result of the arrhythmia. Therefore, the nurse should assess blood pressure later. The nurse also can delay assessing respirations and temperature because these aren't affected by the serum potassium level. A client asks the nurse, "Do you think I should leave my husband?" The nurse responds, "You aren't sure if you should leave your husband?" The nurse is using which therapeutic technique? 1. Restating 2. Reframing 3. Reflecting NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2023 4. Offering a general lead ✅Correct Answer: 3 RATIONALES: Reflecting is correct because the nurse is referring feelings back to the client to explore. When restating, the nurse simply repeats what the client said. Reframing is offering a new way to look at a situation. The nurse's response is specific; it isn't offering a general lead. The nurse is teaching a client about malabsorption syndrome and its treatment. The client asks which part of the GI tract absorbs food. The nurse tells the client that products of digestion are absorbed mainly in the: 1. stomach. 2. small intestine. 3. large intestine. NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2023 2. Occipital lobe 3. Temporal lobe 4. Frontal lobe ✅Correct Answer: 3 RATIONALES: The temporal lobe contains the auditory association area. If the area is damaged in the dominant hemisphere, the client hears words but doesn't know their meaning. Damage to the parietal lobe affects the client's ability to identify special relationships with the environment. When damaged, the occipital lobe affects visual associations. The client can visualize objects but can't identify them. The frontal lobe acts as a storage area for memory. A client with Alzheimer's disease mumbles incoherently and rambles in a confused manner. To help redirect the client's attention, the nurse should encourage the client to: NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2023 1. fold towels and pillowcases. 2. play cards with another client. 3. participate in a game of charades. 4. perform an aerobic exercise. ✅Correct Answer: 1 RATIONALES: Folding towels and pillowcases is a simple activity that redirects the client's attention. Also, because this activity is familiar, the client is likely to perform it successfully. Cards, charades, and aerobic exercise are too complicated for a confused client. The nurse is caring for a 16-year-old pregnant client who is taking an iron supplement. Which instruction should the nurse include when teaching the adolescent about ferrous sulfate? Select all that apply: NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2023 1. Take the supplement with food. 2. Report black stools to the physician immediately. 3. Avoid taking the supplement with milk. 4. Avoid taking the supplement with antacids. 5. Avoid chewing the extended-release form of the drug. ✅Correct Answer: 3,4,5 RATIONALES: Because food delays absorption, the nurse should instruct the client to take the supplement between meals to increase absorption. The client should take the supplement with juice (preferably orange juice) or water, but not with milk or antacids. The nurse should also tell the client not to crush or chew extended-release forms of the drug. NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2023 4. schizophrenia. ✅Correct Answer: 1 RATIONALES: The client's memory of a traumatic childhood incident and her current symptoms (nightmares, flashbacks, and related fears) suggest that she has PTSD with delayed onset. The client doesn't occasionally lose track of her movements and actions, as in multiple personality disorder. Her anxiety isn't primary but results from severe emotional trauma. Although she experiences flashbacks, these aren't psychotic episodes, as in schizophrenia. In a client who's predisposed to bipolar disorder, a bipolar episode might be triggered by: 1. hypothyroidism. 2. hyperglycemia. NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2023 3. hypertension. 4. antiseizure medication. ✅Correct Answer: 1 RATIONALES: Hypothyroidism might trigger a bipolar episode in a client predisposed to bipolar disorder. Episodes aren't known to be triggered by hyperglycemia, hypertension, or antiseizure medications. One aspect of implementation related to drug therapy is: 1. developing a content outline. 2. documenting drugs given. 3. establishing outcome criteria. NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2023 4. setting realistic client goals. ✅Correct Answer: 2 RATIONALES: Although documentation isn't a step in the nursing process, the nurse is legally required to document activities related to drug therapy, including the time of administration, the quantity, and the client's reaction. Developing a content outline, establishing outcome criteria, and setting realistic client goals are parts of planning rather than implementation. A client who sustained an L1 to L2 spinal cord injury in a construction accident asks a nurse if he'll ever be able to walk again. Which response by the nurse is appropriate? 1. "If you keep a positive attitude, you can do anything." 2. "What makes you think you won't be able to walk again?" 3. "What has your physician told you about your ability to walk again?" NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2023 3. Prescribed medications 4. Medications as needed, judiciously ✅Correct Answer: 1 RATIONALES: Providing a safe environment is the most important aspect of caring for a client with delirium. Although all other options are logical and appropriate, meeting the client's safety needs takes priority. The surgeon is discussing surgery with a client diagnosed with colon cancer. The client is visibly shaken over the possibility of acolostomy. Based on the client's response, the surgeon should collaborate with which health team member? 1. Social worker 2. Staff nurse NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2023 3. Clinical educator 4. Enterostomal nurse ✅Correct Answer: 4 RATIONALES: The surgeon should collaborate with the enterostomal nurse who can address the client's concerns. The enterostomal nurse may schedule a visit from a client who has a colostomy to offer support to the client. The clinical educator can provide information about the colostomy when the client is ready to learn. The staff nurse and social worker don't need to be consulted in this situation. A client, age 21, is admitted with bacterial meningitis. Which hospital room would be the appropriate choice for this client? 1. A private room down the hall from the nurses' station NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2023 2. An isolation room close to the nurses' station 3. A semiprivate room with a 32-year-old client who has viral meningitis 4. A two-bed room with a client who previously had bacterial meningitis ✅Correct Answer: 2 RATIONALES: A client with bacterial meningitis should be kept in isolation for at least 24 hours after admission and, during the initial acute phase, should be as close to the nurses' station as possible to allow maximal observation. Placing the client in a room with a client who has viral meningitis may cause harm to both clients because the organisms causing viral and bacterial meningitis differ; either client may contract the other's disease. Immunity to bacterial meningitis can't be acquired; therefore, a client who previously had bacterial meningitis shouldn't be put at risk by rooming with a client who has just been diagnosed with this disease. Which psychological or personality factor is likely to predispose an individual to medication abuse? NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2023 The nurse is performing a neurologic assessment on a 1-day-old neonate. Which of the following findings would indicate possible asphyxia in utero? Select all that apply: 1. The neonate grasps the nurse's finger when she puts it in the palm of his hand. 2. The neonate does stepping movements when held upright with his sole touching a surface. 3. The neonate's toes don't curl downward when his soles are stroked. 4. The neonate doesn't respond when the nurse claps her hands above him. 5. The neonate turns toward an object when the nurse touches his cheek with it. NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2023 6. The neonate displays weak, ineffective sucking. ✅Correct Answer: 3,4,6 RATIONALES: Failure of the toes to curl downward when the baby's soles are stroked and lack of response to a loud sound can be evidence that neurological damage from asphyxia has occurred. The normal responses would be that the toes curl downward with stroking and that the arms and legs extend in response to a loud noise. Weak, ineffective sucking is another sign of neurologic damage; a neonate should root and suck when the side of his cheek is stroked. A neonate should also grasp a person's finger when it's placed in the palm of his hand, do stepping movements when held upright with the soles touching a surface, and turn toward an object when his cheek is touched by it. The mother of a 3-year-old has been told that her child has a brain tumor. She initially begins to cry and accuses the physicians oflying. Which of the following stages is the mother most likely experiencing? 1. Acceptance NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2023 2. Psychotic episode 3. Anger 4. Denial ✅Correct Answer: 3 RATIONALES: Anger is the stage of grief in which a person expresses anger about the diagnosis or situation. Acceptance occurs when the person comes to terms with the diagnosis. This situation isn't an example of a psychotic episode; it's a normal stage of the grieving process. Denial is the stage of grief when a person refuses to believe the truth. A client with pregnancy-induced hypertension (PIH) receives magnesium sulfate, 4 g in 50% solution I.V. over 20 minutes. What is the purpose of administering magnesium sulfate to this client? 1. To lower blood pressure NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2023 1. The nurse's assessment of the client and communication with the family guides the decision-making process. 2. The nurse is an advocate for the client and should encourage the client to accept his current treatment regimen. 3. The health care team must follow the treatment plan that was already established with client and family input. 4. The client has the right to refuse treatment at any time. ✅Correct Answer: 4 RATIONALES: Health care professionals must ensure a health care ethic that respects the role of the client in the decision-making process. According to the Patient's Bill of Rights, the client has the right to make decisions about his care at any time. The nurse should be a client advocate and be supportive of the decision he made. NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2023 A client with newly diagnosed breast cancer asks the nurse, "Why me? I've always been a good person. What have I done to deserve this?" Which response by the nurse would be most therapeutic? 1. "Don't worry. You'll probably live longer than I will." 2. "I'm sure a cure will be found soon." 3. "You seem upset. Let's talk about something happy." 4. "Would you like to talk about this?" ✅Correct Answer: 4 RATIONALES: Listening, responding quickly, and providing support promote therapeutic communication. Offering to talk about the client's feelings validates those feelings and allows the client to express them. NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2023 Options 1 and 2 ignore the client's feelings. Option 3 identifies the client's feelings but doesn't follow through by exploring them. The mother of a 3-year-old child is complaining that her son still throws temper tantrums when he doesn't get his way. How should the nurse advise the mother to respond? 1. Tell the mother to ignore the child because eventually he will stop having temper tantrums. 2. Tell the mother to promise him a new toy if he stops the tantrum. 3. Tell the mother to give in to his demands; he is only 3-years-old. 4. Tell the mother to mimic him so that he can see what his behavior looks like. ✅Correct Answer: 1 NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2023 3. Inform the nurse that she'd like to speak with her, then discuss the inappropriateness of her comment in a private location. 4. Notify the physician of the client's pain and request that he prescribe pain medication for the client. ✅Correct Answer: 3 RATIONALES: The nurse-manager should inform the nurse that she wishes to speak with her. Then, in a private location, she should discuss the inappropriateness of the nurse's comment and an action plan to improve her care. If the client is experiencing pain the nurse should act as a client advocate and notify the physician of the client's pain. However, because the client isn't requesting pain medication, there's no need to request pain medication from the physician. A client is receiving an I.V. infusion of mannitol (Osmitrol) after undergoing intracranial surgery to remove a brain tumor. To determine whether this drug is producing its therapeutic effect, the nurse should consider which finding the most significant? NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2023 1. Decreased level of consciousness (LOC) 2. Elevated blood pressure 3. Increased urine output 4. Decreased heart rate ✅Correct Answer: 3 RATIONALES: The therapeutic effect of mannitol is diuresis, which is confirmed by an increased urine output. A decreased LOC and elevated blood pressure may indicate lack of therapeutic effectiveness. A decreased heart rate doesn't indicate that mannitol is effective. A hospitalized client asks the nurse for "something for pain." Which information is most important for the nurse to gather before administering the medication? Select all that apply: NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2023 1. Administration time of the last dose 2. Client's pain level on a scale of 1 to 10 3. Type of medication the client has been taking 4. Client's reaction to the previous dose 5. Client's most current height and weight 6. Effectiveness of prior dose of medication ✅Correct Answer: 1,2,3,4,6 RATIONALES: The nurse needs to know when the last dose was administered. Some clients request pain medication earlier than is ordered by the physician. Pain, the fifth vital sign, should be assessed using a pain scale and documented in the nursing notes whenever a pain medication is NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2023 3. always be with first morning urine. 4. always be the last evening's void as the last sample. ✅Correct Answer: 2 RATIONALES: When initiating a 24-hour urine specimen, have the client void, and then start timing. The collection should start on an empty bladder. The exact time the test starts isn't important, but it's commonly started in the morning. A client is receiving nitroglycerin ointment (Nitrol) to treat angina pectoris. The nurse evaluates the therapeutic effectiveness of this drug by assessing the client's response and checking for adverse effects. Which vital sign is most likely to reflect an adverse effect of nitroglycerin? 1. Heart rate NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2023 2. Respiratory rate 3. Blood pressure 4. Temperature ✅Correct Answer: 3 RATIONALES: Hypotension and headache are the most common adverse effects of nitroglycerin. Therefore, blood pressure is the vital sign most likely to reflect an adverse effect of this drug. The nurse should check the client's blood pressure 1 hour after administering nitroglycerin ointment. A blood pressure decrease of 10 mm Hg is within the therapeutic range. If blood pressure falls more than 20 mm Hg below baseline, the nurse should remove the ointment and report the finding to the physician immediately. An above-normal heart rate (tachycardia) is a less common adverse effect of nitroglycerin. Respiratory rate and temperature don't change significantly after nitroglycerin administration. Which drugs may be abused because of tolerance and physiologic dependence? NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2023 1. Lithium (Lithobid) and divalproex (Depakote). 2. Verapamil (Calan) and chlorpromazine (Thorazine) 3. Alprazolam (Xanax) and phenobarbital (Luminal) 4. Clozapine (Clozaril) and amitriptyline (Elavil) ✅Correct Answer: 3 RATIONALES: Both benzodiazepines (such as alprazolam) and barbiturates (such as phenobarbital) are addictive, controlled substances. None of the other drugs listed are addictive substances.