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

Download NCLEX-PN 3000 Questions and Answers with Rationales and more Exams Nursing in PDF only on Docsity! NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2024 RATED A+ 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: 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 NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2023 RATED A+ NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2024 RATED A+ 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 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. The nurse must irrigate a gaping abdominal incision with sterile normal saline, using a piston syringe. How should the nurse proceed? 1. Irrigate continuously until the solution becomes clear or all of the solution has been used. 2. Moisten the area around the wound with normal saline after the irrigation. 3. Apply a wet-to-dry dressing to the wound after the irrigation. 4. Rapidly instill a stream of irrigating solution into the wound. ✅Correct Answer: 1 NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2023 RATED A+ NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2024 RATED A+ 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? 1. 18G 2. 20G 3. 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. NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2023 RATED A+ NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2024 RATED A+ Which finding in a neonate suggests hypothermia? 1. Bradycardia 2. Hyperglycemia 3. Metabolic alkalosis 4. Shivering ✅Correct Answer: 1 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? 1. Headache, blurred vision, and facial and extremity swelling 2. Abdominal pain, urinary frequency, and pedal edema NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2023 RATED A+ NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2024 RATED A+ 3. Diaphoresis, nystagmus, and dizziness 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 3. Potential areas of pressure ulcer development 4. Overall risk of developing pressure ulcers ✅Correct Answer: 4 NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2023 RATED A+ NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2024 RATED A+ 2. incontinence. 3. diminished reflexes. 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. 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 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. NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2023 RATED A+ NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2024 RATED A+ 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 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 4. Tissue plasminogen activator (tPA) ✅Correct Answer: 4 NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2023 RATED A+ NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2024 RATED A+ 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. 3. 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. NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2023 RATED A+ NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2024 RATED A+ 2. Cerebral edema 3. Low cerebrospinal fluid (CSF) pressure 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. 4. stimulating or hindering micturition. ✅Correct Answer: 4 NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2023 RATED A+ NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2024 RATED A+ 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? 1. Small pieces of banana 2. Large, round chunks of meat such as hot dog 3. 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 NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2023 RATED A+ NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2024 RATED A+ 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? 1. Insulin 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 RATED A+ NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2024 RATED A+ growth, the nurse should hang only the amount of formula that can be infused in 8 hours. When taking a dietary history from a newly admitted client, the nurse should remember that which of the following foods is a commonallergen? 1. Bread 2. Carrots 3. Oranges 4. Strawberries ✅Correct Answer: 4 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. NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2023 RATED A+ NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2024 RATED A+ 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? 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 RATED A+ NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2024 RATED A+ 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 one is being persecuted. A delusion of reference is a false belief that one is connected to events unrelated to oneself or a belief that one is responsible for the evil in the world. A toddler is having a tonic-clonic seizure. What should the nurse do first? 1. Restrain the child. NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2023 RATED A+ NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2024 RATED A+ 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. 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 NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2023 RATED A+ NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2024 RATED A+ necrotizing fasciitis is suspected. Another manifestation that would most suggest necrotizing fasciitis is: 1. erythema. 2. leukocytosis. 3. pressurelike pain. 4. swelling. ✅Correct Answer: 3 RATIONALES: Severe pressurelike pain out of proportion to visible signs distinguishes necrotizing fasciitis from cellulitis. Erythema, leukocytosis, and swelling are present in both cellulitis and necrotizing fasciitis. A 42-year-old client comes to the clinic and is diagnosed with shingles. Which findings confirm this diagnosis? Select all that apply: 1. Severe, deep pain around the thorax 2. Red, nodular skin lesions around the thorax NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2023 RATED A+ NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2024 RATED A+ 3. Fever 4. Malaise 5. Diarrhea ✅Correct Answer: 1,2,3,4 RATIONALES: Shingles, also called herpes zoster, is an acute unilateral and segmental inflammation of the dorsal root ganglia. It's caused by infection with the herpes virus varicella-zoster, the same virus that causes chickenpox. It commonly causes severe, deep pain along a 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? 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." NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2023 RATED A+ NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2024 RATED A+ 2. They will decrease the need for insulin. 3. They will increase the need for insulin. 4. They will cause wide fluctuations in the need for insulin. ✅Correct Answer: 3 RATIONALES: Insulin requirements are increased by growth, pregnancy, increased food intake, stress, surgery, infection, illness, increased insulin antibodies, and some medications. Insulin requirements are decreased by hypothyroidism, decreased food intake, exercise, and some medications. A school-age child with terminal leukemia is admitted to the pediatric unit. The nurse must discuss advance directives with the child's parents. The nurse should include which information? 1. Positive appraisal of the child's prognosis 2. Chemotherapy options 3. Comfort care options NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2023 RATED A+ NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2024 RATED A+ 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 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. NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2023 RATED A+ NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2024 RATED A+ 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. 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 RATED A+ NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2024 RATED A+ 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. 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 NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2023 RATED A+ NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2024 RATED A+ 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: 1. hypotension. 2. hypertension. 3. seizures. 4. renal toxicity. ✅Correct Answer: 1 RATIONALES: In a client with PIH, uteroplacental perfusion may be inadequate and gas exchange may be poor. Regional anesthesia increases the risk of hypotension resulting from sympathetic blockade, possibly causing fetal and maternal hypoxia. Hypertension, seizures, and renal toxicity aren't associated with regional anesthesia. A postpartum client requires teaching about breast-feeding. To prevent breast engorgement, the nurse should instruct her to: NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2023 RATED A+ NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2024 RATED A+ 1. use an electric breast pump. 2. apply warm, moist compresses to the breasts. 3. breast-feed every 1½ to 3 hours. 4. wear a brassiere 24 hours per day. ✅Correct Answer: 3 RATIONALES: Frequent breast-feeding empties the breasts and increases circulation, helping to remove fluid that may lead to engorgement. If the infant isn't ill or physically impaired and can breast-feed, the client shouldn't use an electric breast pump because this deprives the infant of optimal sucking and skin-to-skin contact with the mother. Applying warm, moist 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 NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2023 RATED A+ NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2024 RATED A+ Which interventions are appropriate when caring for a client with acute thrombophlebitis? 1. Apply cool soaks and keep the client's leg lower than the level of the heart. 2. Increase the client's activity level and encourage leg exercises. 3. Apply cool soaks and administer nitroglycerin. 4. Apply warm soaks and elevate the client's legs higher than the level of the heart. ✅Correct Answer: 4 RATIONALES: To help treat thrombophlebitis, the nurse should prevent venostasis with measures such as applying warm soaks and elevating the client's legs. The client should remain on bed rest during the acute phase, after which the client may begin to walk while wearing antiembolism stockings. Treatment for thrombophlebitis may also include anticoagulants to prolong clotting time. Damage to which area of the brain results in receptive aphasia? 1. Parietal lobe NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2023 RATED A+ NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2024 RATED A+ 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: 1. fold towels and pillowcases. 2. play cards with another client. 3. participate in a game of charades. NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2023 RATED A+ NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2024 RATED A+ 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: 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 RATED A+ NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2024 RATED A+ 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. 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. NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2023 RATED A+ NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2024 RATED A+ 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?" 4. "Most likely you won't be able to, but we never know for sure." ✅Correct Answer: 3 RATIONALES: The nurse should respond by asking the client what he's already been told about his ability to walk again. After assessing the client's knowledge, she can better respond to the client's questioning. Option 1 provides the client with false hope, and option 2 may place the client on the defensive. Option 4 is an inappropriate response. While obtaining a health history, the nurse learns that the client is allergic to bee stings. When obtaining this client's medication history, the nurse should determine if the client keeps which medication on hand? 1. diphenhydramine hydrochloride (Benadryl) NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2023 RATED A+ NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2024 RATED A+ 2. pseudoephedrine hydrochloride (Sudafed) 3. guaifenesin (Robitussin) 4. loperamide (Imodium) ✅Correct Answer: 1 RATIONALES: A client who is allergic to bee stings should keep diphenhydramine on hand because its antihistamine action can prevent a severe allergic reaction. Pseudoephedrine is a decongestant, which is used to treat cold symptoms. Guaifenesin is an expectorant, which is used for coughs. Loperamide is an antidiarrheal agent. The nurse is caring for a client with delirium. Which of the following is most important for the nurse to provide the client? 1. A safe environment 2. An opportunity to release frustration 3. Prescribed medications 4. Medications as needed, judiciously ✅Correct Answer: 1 NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2023 RATED A+ NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2024 RATED A+ 3. Dependent personality disorder 4. Antisocial personality disorder ✅Correct Answer: 1 RATIONALES: Low self-esteem and repressed rage as well as depression can predispose an individual to search for solace in addictive medications. Usually, medications are used to minimize or blot out pain, rather than inflict additional pain. Personality disorders don't predispose a client to medication abuse; however, personality disorders, especially the antisocial ones, may be intensified by abuse. Which detail of a client's drug therapy is the nurse legally responsible for documenting? 1. Peak concentration time of the drug 2. Safe ranges of the drug 3. Client's socioeconomic data 4. Client's reaction to the drug ✅Correct Answer: 4 NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2023 RATED A+ NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2024 RATED A+ RATIONALES: The nurse legally must document the client's reaction to the drug in addition to the time the drug was administered and the dosage given. The nurse isn't legally responsible for documenting the peak concentration time of the drug, safe drug ranges, or the client's socioeconomic data. 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. 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 NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2023 RATED A+ NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2024 RATED A+ 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 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. NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2023 RATED A+ NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2024 RATED A+ 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. 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. Options 1 and 2 ignore the client's feelings. Option 3 identifies the client's feelings but doesn't follow through by exploring them. NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2023 RATED A+ NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2024 RATED A+ 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 RATIONALES: This child is in Erikson's developmental stage of initiative versus guilt. Guilt develops when the child is made to feel bad about his behavior. Ignoring the negative behavior shows the child that he'll gain nothing through negative behavior such as temper tantrums. Promising the child a new toy or giving in to his demands will reinforce his negative behavior by rewarding his tantrums. Mimicking the child will make him feel guilty. A client asks the nurse about the rhythm (calendar-basal body temperature) method of family planning. The nurse explains that this method involves: 1. chemical barriers that act as spermicidal agents. NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2023 RATED A+ NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2024 RATED A+ 2. hormones that prevent ovulation. 3. mechanical barriers that prevent sperm from reaching the cervix. 4. determination of the fertile period to identify safe times for sexual intercourse. ✅Correct Answer: 4 RATIONALES: The rhythm method of family planning combines basal body temperature measurement with analysis of cervical mucus changes to determine the fertile period. This method helps identify safe and unsafe periods for sexual intercourse. A natural family planning method, the rhythm method doesn't involve use of chemical barriers, hormones, or mechanical barriers. The nurse-manager overhears a nurse tell a client, "If I were you, I'd ask the doctor for something for pain; you shouldn't have to suffer during labor." How should the nurse-manager respond to the nurse's comment? 1. Don't respond because the nurse's statement is correct. 2. Confront the nurse in the client's room and remind her that it's inappropriate to administer pain medications to clients in labor. NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2023 RATED A+ NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2024 RATED A+ given. Pain is usually reassessed about 30 minutes after the medication is given. Physicians commonly order several different types of pain medication based on the client's condition. The nurse should know which medication and which route was used to administer prior dosages. Evaluating the effectiveness of medications is also an important nursing function when managing the client's pain. Therefore, she should ask the client if the prior dose was helpful. The nurse should also note whether the client experienced any adverse effects of the medication. Most medications are ordered based on the client's admission weight, not current weight and height. A client's weight may fluctuate when he's in the hospital, so it's unlikely that the nurse will have the most current weight available. Also, taking steps to obtain the client's current weight postpones the pain treatment and can potentially worsen pain. The nurse collects data on a client shortly after kidney transplant surgery. Which postoperative finding must the nurse report to the physician immediately? 1. Serum potassium level of 4.9 mEq/L 2. Serum sodium level of 135 mEq/L 3. Temperature of 99.2° F (37.3° C) 4. Urine output of 20 ml/hour ✅Correct Answer: 4 RATIONALES: Because kidney transplantation carries the risk of transplant rejection, infection, and other serious complications, the nurse should NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2023 RATED A+ NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2024 RATED A+ monitor the client's urinary function closely. A decrease from the normal urine output of 30 ml/hour is significant and warrants immediate physician notification. The other options are normal data collection findings. A client receiving total parental nutrition is prescribed a 24-hour urine test. When initiating a 24-hour urine specimen, the collectiontime should: 1. start with the first voiding. 2. start after a known voiding that empties the bladder. 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 RATED A+ NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2024 RATED A+ 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? 1. Lithium (Lithobid) and divalproex (Depakote). 2. Verapamil (Calan) and chlorpromazine (Thorazine) NCLEX-PN 3000 Questions and Answers with Rationales Latest Update 2023 RATED A+