NCLEX PN EXAM 2023 QUESTIONS AND ANSWERS WITH EXPLANATIONS A+ SUCCESS ASSURED, Exams of Nursing

Download NCLEX PN EXAM 2023 QUESTIONS AND ANSWERS WITH EXPLANATIONS A+ SUCCESS ASSURED and more Exams Nursing in PDF only on Docsity! NCLEX PN EXAM 2023 QUESTIONS AND ANSWERS WITH EXPLANATIONS A+ SUCCESS ASSURED  The child with seizure disorder is being treated with Dilantin (phenytoin). Which of the following statements by the patient’s mother indicates to the nurse that the patient is experiencing a side effect of Dilantin therapy? A. “She is very irritable lately.” B. “She sleeps quite a bit of the time.” C. “Her gums look too big for her teeth.” D. “She has gained about 10 pounds in the last 6 months.” Answer C: Hyperplasia of the gums is associated with Dilantin therapy. Answer A is not related to the therapy; answer B is a side effect, and answer D is not related to the question.  A 5-year-old is admitted to the unit following a tonsillectomy. Which of the following would indicate a complication of the surgery? A. Decreased appetite B. A low-grade fever C. Chest congestion D. Constant swallowing Answer D: A complication of a tonsillectomy is bleeding, and constant swallowing may indicate bleeding. Decreased appetite is expected after a tonsillectomy, as is a low-grade temperature; thus, answers A and B are incorrect. In answer C, chest congestion is not normal but is not associated with the tonsillectomy.  A 6-year-old with cerebral palsy functions at the level of an 18-monthold. Which finding would support that assessment? A. She dresses herself. NCLEX PN EXAM 2023 QUESTIONS AND ANSWERS WITH EXPLANATIONS A+ SUCCESS ASSURED B. She pulls a toy behind her. C. She can build a tower of eight blocks. D. She can copy a horizontal or vertical line. Answer B: Children at 18 months of age like push-pull toys. Children at approximately 3 years of age begin to dress themselves and build a tower of eight blocks. At age four, children can copy a horizontal or vertical line. Therefore, answers A, C, and D are incorrect.  Which information obtained from the mother of a child with cerebral palsy most likely correlates to the diagnosis? A. She was born at 42 weeks gestation. B. She had meningitis when she was 6 months old. C. She had physiologic jaundice after delivery. D. She has frequent sore throats. Answer B: The diagnosis of meningitis at age 6 months correlates to a diagnosis of cerebral palsy. Cerebral palsy, a neurological disorder, is often associated with birth trauma or infections of the brain or spinal column. Answers A, C, and D are not related to the question.  A 10-year-old is being treated for asthma. Before administering Theodur, the nurse should check the: A. Urinary output B. Blood pressure C. Pulse D. Temperature Answer C: Theodur is a bronchodilator, and a side effect of bronchodilators is tachycardia, so checking the pulse is important. Extreme tachycardia should be reported to the doctor. Answers A, B, and D are not necessary. 106. An elderly client is diagnosed with ovarian cancer. She has surgery followed by chemotherapy with a fluorouracil (Adrucil) IV. What should the nurse do if she notices crystals and cloudiness in the IV medication? A. Discard the solution and order a new bag B. Warm the solution NCLEX PN EXAM 2023 QUESTIONS AND ANSWERS WITH EXPLANATIONS A+ SUCCESS ASSURED D. Morning administration mimics the body’s natural secretion of corticosteroid. Answer D: Taking corticosteroids in the morning mimics the body’s natural release of cortisol. Answers A is not necessarily true, and answers B and C are not true.  A 20-year-old female has a prescription for tetracycline. While teaching the client how to take her medicine, the nurse learns that the client is also taking Ortho-Novum oral contraceptive pills. Which instructions should be included in the teaching plan? A. The oral contraceptives will decrease the effectiveness of the tetracycline. B. Nausea often results from taking oral contraceptives and antibiotics. C. Toxicity can result when taking these two medications together. D. Antibiotics can decrease the effectiveness of oral contraceptives, so the client should use an alternate method of birth control. Answer D: Taking antibiotics and oral contraceptives together decreases the effectiveness of the oral contraceptives. Answers A, B, and C are not necessarily true.  A 60-year-old diabetic is taking glyburide (Diabeta) 1.25mg daily to treat Type II diabetes mellitus. Which statement indicates the need for further teaching? A. “I will keep candy with me just in case my blood sugar drops.” B. “I need to stay out of the sun as much as possible.” C. “I often skip dinner because I don’t feel hungry.” D. “I always wear my medical identification.” Answer C: The client should be taught to eat his meals even if he is not hungry, to prevent a hypoglycemic reaction. Answers A, B, and D are incorrect because they indicate an understanding of the nurse’s teaching.  The physician prescribes regular insulin, 5 units subcutaneous. Regular insulin begins to exert an effect: NCLEX PN EXAM 2023 QUESTIONS AND ANSWERS WITH EXPLANATIONS A+ SUCCESS ASSURED A. In 5–10 minutes B. In 10–20 minutes NCLEX PN EXAM 2023 QUESTIONS AND ANSWERS WITH EXPLANATIONS A+ SUCCESS ASSURED C. In 30–60 minutes D. In 60–120 minutes Answer C: The time of onset for regular insulin is 30–60 minutes; therefore, answers A, B, and D are incorrect.  The client is admitted from the emergency room with multiple injuries sustained from an auto accident. His doctor prescribes a histamine blocker. The reason for this order is: A. To treat general discomfort B. To correct electrolyte imbalances C. To prevent stress ulcers D. To treat nausea Answer C: Histamine blockers are frequently ordered for clients who are hospitalized for prolonged periods and who are in a stressful situation. They are not used to treat discomfort, correct electrolytes, or treat nausea; therefore, answers A, B, and D are incorrect.  The client with a recent liver transplant asks the nurse how long he will have to take cyclosporine (Sandimmune). Which response is correct? A. 1 year B. 5 years C. 10 years D. The rest of his life Answer D: Cyclosporin is an immunosuppressant, and the client with a liver transplant will be on immunosuppressants for the rest of his life. Answers A, B, and C, therefore, are incorrect.  Shortly after the client was admitted to the postpartum unit, the nurse notes heavy lochia rubra with large clots. The nurse should anticipate an order for: A. Methergine NCLEX PN EXAM 2023 QUESTIONS AND ANSWERS WITH EXPLANATIONS A+ SUCCESS ASSURED B. 30 minutes before the fourth dose C. 30 minutes after the first dose D. 30 minutes after the fourth dose Answer B: Trough levels are the lowest blood levels and should be done 30 minutes before the third IV dose or 30 minutes before the fourth IM dose. Answers A, C, and D are incorrect.  A 4-year-old with cystic fibrosis has a prescription for Viokase pancreatic enzymes to prevent malabsorption. The correct time to give pancreatic enzyme is: A. 1 hour before meals B. 2 hours after meals C. With each meal and snack D. On an empty stomach Answer C: Viokase is a pancreatic enzyme that is used to facilitate digestion. It should be given with meals and snacks, and it works well in foods such as applesauce. Answers A, B, and D are incorrect times to administer this medication.  Isoniazid (INH) has been prescribed for a family member exposed to tuberculosis. The nurse is aware that the length of time that the medication will be taken is: A. 6 months B. 3 months C. 18 months D. 24 months Answer A: The expected time for contact to tuberculosis is 1 year. Therefore, answers B, C, and D are incorrect.  The client is admitted to the postpartum unit with an order to continue the infusion of Pitocin. Which finding indicates that the Pitocin is having the desired effect? A. The fundus is deviated to the left. NCLEX PN EXAM 2023 QUESTIONS AND ANSWERS WITH EXPLANATIONS A+ SUCCESS ASSURED B. The fundus is firm and in the midline. NCLEX PN EXAM 2023 QUESTIONS AND ANSWERS WITH EXPLANATIONS A+ SUCCESS ASSURED C. The fundus is boggy. D. The fundus is two finger breadths below the umbilicus. Answer B: Pitocin is used to cause the uterus to contract and decrease bleeding. A uterus deviated to the left, as stated in answer A, indicates a full bladder. It is not desirable to have a boggy uterus, making answer C incorrect. This lack of muscle tone will increase bleeding. Answer D is incorrect because the position of the uterus is not related to the use of Pitocin.  The nurse is teaching a group of new graduates about the safety needs of the client receiving chemotherapy. Before administering chemotherapy, the nurse should: A. Administer a bolus of IV fluid B. Administer pain medication C. Administer an antiemetic D. Allow the patient a chance to eat Answer C: Before chemotherapy, an antiemetic should be given because most chemotherapy agents cause nausea. It is not necessary to give a bolus of IV fluids, medicate for pain, or allow the client to eat; therefore, answers A, B, and D are incorrect.  Before administering Methytrexate orally to the client with cancer, the nurse should check the: A. IV site B. Electrolytes C. Blood gases D. Vital signs Answer D: The vital signs should be taken before any chemotherapy agent. If it is an IV infusion of chemotherapy, the nurse should check the IV site as well. Answers B and C are incorrect because it is not necessary to check the electrolytes or blood gases.  Vitamin K (aquamephyton) is administered to a newborn NCLEX PN EXAM 2023 QUESTIONS AND ANSWERS WITH EXPLANATIONS A+ SUCCESS ASSURED  The client arrives in the emergency room with a hyphema. Which action by the nurse would be best? NCLEX PN EXAM 2023 QUESTIONS AND ANSWERS WITH EXPLANATIONS A+ SUCCESS ASSURED A. Elevate the head of the bed and apply ice to the eye B. Place the client in a supine position and apply heat to the knee C. Insert a Foley catheter and measure the intake and output D. Perform a vaginal exam and check for a discharge Answer A: Hyphema is blood in the anterior chamber of the eye and around the eye. The client should have the head of the bed elevated and ice applied. Answers B, C, and D are incorrect and do not treat the problem.  The nurse is making assignments for the day. Which client should be assigned to the nursing assistant? A. The 18-year-old with a fracture to two cervical vertebrae B. The infant with meningitis C. The elderly client with a thyroidectomy 4 days ago D. The client with a thoracotomy 2 days ago Answer C: The most stable client is the client with the thyroidectomy 4 days ago. Answers A, B, and D are incorrect because the other clients are less stable and require a registered nurse.  The client arrives in the emergency room with a “bull’s eye” rash. Which question would be most appropriate for the nurse to ask the client? A. “Have you found any ticks on your body?” B. “Have you had any nausea in the last 24 hours?” C. “Have you been outside the country in the last 6 months?” D. “Have you had any fever for the past few days?” Answer A: The “bull’s eye” rash is indicative of Lyme’s disease, a disease spread by ticks. The signs and symptoms include elevated temperature, headache, nausea, and the rash. Although answers B and D are important, the question asks which would be best. Answer C has no significance.  Which of the following is the best indicator of the diagnosis of HIV? A. White blood cell count B. ELISA C. Western Blot NCLEX PN EXAM 2023 QUESTIONS AND ANSWERS WITH EXPLANATIONS A+ SUCCESS ASSURED D. Complete blood count NCLEX PN EXAM 2023 QUESTIONS AND ANSWERS WITH EXPLANATIONS A+ SUCCESS ASSURED B. Explain to the nurse that there is no risk to the client C. Ask the nurse if the chickenpox have scabbed D. Ask the nurse if she has ever had the chickenpox Answer D: The nurse who has had the chickenpox has immunity to the illness. Answer A is incorrect because more information is needed to determine whether a change in assignment is necessary. Answer B is incorrect because there could be a risk to the immune-suppressed client. Answer C is incorrect because the client who is immune-suppressed could still be at risk from the nurse’s exposure to the chickenpox, even if scabs are present.  The client with brain cancer refuses to care for herself. Which action by the nurse would be best? A. Alternate nurses caring for the client so that the staff will not get tired of caring for this client B. Talk to the client and explain the need for self-care C. Explore the reason for the lack of motivation seen in the client D. Talk to the doctor about the client’s lack of motivation Answer C: The nurse should explore the cause for the lack of motivation. The client might be anemic and lack energy, might be in pain, or might be depressed. Alternating staff, as stated in answer A, will prevent a bond from being formed with the nurse. Answer B is not enough, and answer D is not necessary.  The nurse is caring for the client who has been in a coma for 2 months. He has signed a donor card, but the wife is opposed to the idea of organ donation. How should the nurse handle the topic of organ donation with the wife? A. Contact organ retrieval to come talk to the wife B. Tell her that because her husband signed a donor card, the hospital has the right to take the organs upon the death of her husband C. Drop the subject until a later time D. Refrain from talking about the subject until after the death of her husband Answer A: Contacting organ retrieval to talk to the family member is the NCLEX PN EXAM 2023 QUESTIONS AND ANSWERS WITH EXPLANATIONS A+ SUCCESS ASSURED best choice because a trained specialist has the knowledge to assist the wife with making the decision to donate or not to donate the client’s organs. The hospital will certainly honor the wishes of family members even if the patient has signed a donor card. Answer B is incorrect; answer C might be done, but there might not be time; and answer D is not good nursing etiquette and, therefore, is incorrect.  The nurse is assessing the abdomen. The nurse knows the best sequence to perform the assessment is: A. Inspection, auscultation, palpation B. Auscultation, palpation, inspection C. Palpation, inspection, auscultation D. Inspection, palpation, auscultation Answer A: The nurse should inspect first, then auscultate, and finally palpate. If the nurse palpates first, the assessment might be unreliable. Therefore, answers B, C, and D are incorrect.  The nurse is assisting in the assessment of the patient admitted with abdominal pain. Why should the nurse ask about medications that the client is taking? A. Interactions between medications can be identified. B. Various medications taken by mouth can affect the alimentary tract. C. This will provide an opportunity to educate the patient regarding the medications used. D. The types of medications might be attributable to an abdominal pathology not already identified. Answer B: Many medications can irritate the stomach and contribute to abdominal pain. For answer A, the primary reason for asking about medications is not to identify interactions between medication. Although this might provide an opportunity for teaching, this is not the best time to teach. Therefore, answers C and D are incorrect.  The nurse is asked by the nurse aide, “Are peptic ulcers really caused by stress?” The nurse would be correct in replying with which of the following: NCLEX PN EXAM 2023 QUESTIONS AND ANSWERS WITH EXPLANATIONS A+ SUCCESS ASSURED A. “Peptic ulcers result from overeating fatty foods.” NCLEX PN EXAM 2023 QUESTIONS AND ANSWERS WITH EXPLANATIONS A+ SUCCESS ASSURED A. Assess for tube placement by aspirating stomach content B. Place the patient in a left-lying position NCLEX PN EXAM 2023 QUESTIONS AND ANSWERS WITH EXPLANATIONS A+ SUCCESS ASSURED C. Administer feeding with 50% H20 concentration D. Ensure that the feeding solution has been warmed in a microwave for 2 minutes Answer A: Before beginning feedings, an x-ray is often obtained to check for placement. Aspirating stomach content and checking the pH for acidity is the best method of checking for placement. Other methods include placing the end in water and checking for bubbling, and injecting air and listening over the epigastric area. Answers B and C are not correct. Answer D is incorrect because warming in the microwave is contraindicated.  The patient is prescribed metronidazole (Flagyl) for adjunct treatment for a duodenal ulcer. When teaching about this medication, the nurse would say: A. “This medication should be taken only until you begin to feel better.” B. “This medication should be taken on an empty stomach to increase absorption.” C. “While taking this medication, you do not have to be concerned about being in the sun.” D. “While taking this medication, alcoholic beverages and products containing alcohol should be avoided.” Answer D: Alcohol will cause extreme nausea if consumed with Flagyl. Answer A is incorrect because the full course of treatment should be taken. The medication should be taken with a full 8oz. of water, with meals, and the client should avoid direct sunlight because he will most likely be photosensitive; therefore, answers A, B, and C are incorrect.  In planning care for the patient with ulcerative colitis, the nurse identifies which nursing diagnoses as a priority? A. Anxiety B. Impaired skin integrity C. Fluid volume deficit D. Nutrition altered, less than body requirements Answer C: Fluid volume deficit can lead to metabolic acidosis and NCLEX PN EXAM 2023 QUESTIONS AND ANSWERS WITH EXPLANATIONS A+ SUCCESS ASSURED electrolyte loss. The other nursing diagnoses in answers A, B, and D might be applicable but are of lesser priority.  The nurse is teaching about irritable bowel syndrome (IBS). Which of the following would be most important? A. Reinforcing the need for a balanced diet B. Encouraging the client to drink 16 ounces of fluid with each meal C. Telling the client to eat a diet low in fiber D. Instructing the client to limit his intake of fruits and vegetables Answer A: The nurse should reinforce the need for a diet balanced in all nutrients and fiber. Foods that often cause diarrhea and bloating associated with irritable bowel syndrome include fried foods, caffeinated beverages, alcohol, and spicy foods. Therefore, answers B, C, and D are incorrect. 148. The nurse is planning care for the patient with celiac disease. In teaching about the diet, the nurse should instruct the patient to avoid which of the following for breakfast? A. Cream of wheat B. Banana C. Puffed rice D. Cornflakes Answer A: Clients with celiac disease should refrain from eating foods containing gluten. Foods with gluten include wheat barley, oats, and rye. The other foods are allowed.  The nurse is caring for a patient with suspected diverticulitis. The nurse would be most prudent in questioning which of the following diagnostic tests ordered? A. Colonoscopy B. Barium enema C. Complete blood count D. Computed tomography (CT) scan Answer B: A barium enema is contraindicated in the client with diverticulitis NCLEX PN EXAM 2023 QUESTIONS AND ANSWERS WITH EXPLANATIONS A+ SUCCESS ASSURED Answer C: Epidural anesthesia involves injecting an anesthetic into the epidural space. If the anesthetic rises above the respiratory center, the client will have impaired breathing; thus, monitoring for respiratory depression is necessary. Answer A, seizure activity, is not likely after an epidural. Answer B, orthostatic hypotension, occurs when the client stands up but is not a monitoring action. The client with an epidural anesthesia must remain flat on her back and should not stand up for 24 hours. Answer D, hematuria, is not related to epidural anesthesia.  The nurse is performing an assessment of an elderly client with a total hip repair. Based on this assessment, the nurse decides to medicate the client with an analgesic. Which finding most likely prompted the nurse to decide to administer the analgesic? A. The client’s blood pressure is 130/86. B. The client is unable to concentrate. C. The client’s pupils are dilated. D. The client grimaces during care. Answer D: Facial grimace is an indication of pain. The blood pressure in answer A is within normal limits. The client’s inability to concentrate, along with dilated pupils, as stated in answers B and C, may be related to the anesthesia that he received during surgery.  A client who has chosen to breastfeed complains to the nurse that her nipples became very sore while she was breastfeeding her older child. Which measure will help her to avoid soreness of the nipples? A. Feeding the baby during the first 48 hours after delivery B. Breaking suction by placing a finger between the baby’s mouth and the breast when she terminates the feeding C. Applying warm, moist soaks to the breast several times per day D. Wearing a support bra Answer B: To decrease the potential for soreness of the nipples, the client should be taught to break the suction before removing the baby from the breast. Answer A is incorrect because feeding the baby during the first 48 NCLEX PN EXAM 2023 QUESTIONS AND ANSWERS WITH EXPLANATIONS A+ SUCCESS ASSURED hours after delivery will provide colostrum but will not help the soreness of the nipples. Answers C and D are incorrect because applying warm, moist NCLEX PN EXAM 2023 QUESTIONS AND ANSWERS WITH EXPLANATIONS A+ SUCCESS ASSURED soaks and wearing a support bra will help with engorgement but will not help the nipples.  The nurse asked the client if he has an advance directive. The reason for asking the client this question is: A. She is curious about his plans regarding funeral arrangements. B. Much confusion can occur with the client’s family if he does not have an advanced directive. C. An advanced directive allows the medical personnel to make all decisions for the client. D. An advanced directive allows active euthanasia. Answer B: An advanced directive allows the client to make known his wishes regarding care if he becomes unable to act on his own. Much confusion regarding life-saving measures can occur if the client does not have an advanced directive. Answers A, C, and D are incorrect because the nurse doesn’t need to know about funeral plans and cannot make decisions for the client, and active euthanasia is illegal in most states in the United States.  The doctor has ordered a Transcutaneous Electrical Nerve Stimulation (TENS) unit for the client with chronic back pain. The nurse teaching the client with a TENS unit should tell the client: A. “You may be electrocuted if you use water with this unit.” B. “Please report skin irritation to the doctor.” C. “The unit may be used anywhere on the body without fear of adverse reactions.” D. “A cream should be applied to the skin before applying the unit.” Answer B: Skin irritation can occur if the TENS unit is used for prolonged periods of time. To prevent skin irritations, the client should change the location of the electrodes often. Electrocution is not a risk because it uses a battery pack; thus, answer A is incorrect. Answer C is incorrect because the unit should not be used on sensitive areas of the body. Answer D is incorrect because no creams are to be used with the device.  The doctor has ordered a patient-controlled analgesia (PCA) pump for the client with chronic pain. The client asks the nurse if he NCLEX PN EXAM 2023 QUESTIONS AND ANSWERS WITH EXPLANATIONS A+ SUCCESS ASSURED just as they would temperature, respirations, pulse, and blood pressure. Answers A, C, and D are included in the charting but are not considered to be the fifth vital sign and are, therefore, incorrect.  The client with AIDS tells the nurse that he has been using acupuncture to help with his pain. The nurse should question the client regarding this treatment because acupuncture: A. Uses pressure from the fingers and hands to stimulate the energy points in the body B. Uses oils extracted from plants and herbs C. Uses needles to stimulate certain points on the body to treat pain D. Uses manipulation of the skeletal muscles to relieve stress and pain Answer C: Acupuncture uses needles, and because HIV is transmitted by blood and body fluids, the nurse should question this treatment. Answer A describes acupressure, and answers B and D describe massage therapy with the use of oils.  The client has an order for heparin to prevent post-surgical thrombi. Immediately following a heparin injection, the nurse should: A. Aspirate for blood B. Check the pulse rate C. Massage the site D. Check the site for bleeding Answer D: After administering any subcutaneous anticoagulant, the nurse should check the site for bleeding. Answers A and C are incorrect because aspirating and massaging the site are not done. Checking the pulse is not necessary, as in answer B.  Which of the following lab studies should be done periodically if the client is taking sodium warfarin (Coumadin)? A. Stool specimen for occult blood B. White blood cell count C. Blood glucose D. Erthyrocyte count NCLEX PN EXAM 2023 QUESTIONS AND ANSWERS WITH EXPLANATIONS A+ SUCCESS ASSURED Answer A: An occult blood test should be done periodically to detect any intestinal bleeding on the client with coumadin therapy. Answers B, C, and D are not directly related to the question.  The doctor has ordered 80mg of furosemide (Lasix) two times per day. The nurse notes the patient’s potassium level to be 2.5meq/L. The nurse should: A. Administer the Lasix as ordered B. Administer half the dose C. Offer the patient a potassium-rich food D. Withhold the drug and call the doctor Answer D: The potassium level of 2.5meq/L is extremely low. The normal is 3.5–5.5meq/L. Lasix (furosemide) is a nonpotassium sparing diuretic, so answer A is incorrect. The nurse cannot alter the doctor’s order, as stated in answer B, and answer C will not help with this situation.  The doctor is preparing to remove chest tubes from the client’s left chest. In preparation for the removal, the nurse should instruct the client to: A. Breathe normally B. Hold his breath and bear down C. Take a deep breath D. Sneeze on command Answer B: The client should be asked to perform Valsalva maneuver while the chest tube is being removed. This prevents changes in pressure until an occlusive dressing can be applied. Answers A and C are not recommended, and sneezing is difficult to perform on command.  The nurse identifies ventricular tachycardia on the heart monitor. Which action should the nurse prepare to take? A. Administer atropine sulfate B. Check the potassium level C. Administer an antiarrythmic medication such as Lidocaine D. Defibrillate at 360 joules NCLEX PN EXAM 2023 QUESTIONS AND ANSWERS WITH EXPLANATIONS A+ SUCCESS ASSURED Answer C: The treatment for ventricular tachycardia is lidocaine. A NCLEX PN EXAM 2023 QUESTIONS AND ANSWERS WITH EXPLANATIONS A+ SUCCESS ASSURED A. Apply ice to the scrotum B. Elevate the scrotum on a small pillow NCLEX PN EXAM 2023 QUESTIONS AND ANSWERS WITH EXPLANATIONS A+ SUCCESS ASSURED C. Apply heat to the abdominal area D. Administer a diuretic Answer B: The child with nephotic syndrome will exhibit extreme edema. Elevating the scrotum on a small pillow will help with the edema. Applying ice is contraindicated; heat will increase the edema. Administering a diuretic might be ordered, but it will not directly help the scrotal edema. Therefore, answers A, C, and D are incorrect.  The nurse is taking the blood pressure of an obese client. If the blood pressure cuff is too small, the results will be: A. A false elevation B. A false low reading C. A blood pressure reading that is correct D. A subnormal finding Answer A: If the blood pressure cuff is too small, the result will be a blood pressure that is a false elevation. Answers B, C, and D are incorrect. If the blood pressure cuff is too large, a false low will result. Answers C and D have basically the same meaning.  The client is admitted with thrombophlebitis and an order for heparin. The medication should be administered using: A. Buretrol B. A tuberculin syringe C. Intravenous controller D. Three-way stop-cock Answer B: To safely administer heparin, the nurse should obtain an infusion controller. Too rapid infusion of heparin can result in hemorrhage. Answers A, C, and D are incorrect. It is not necessary to have a buretrol, an infusion filter, or a three-way stop-cock.  The client is admitted to the hospital in chronic renal failure. A diet low in protein is ordered. The rationale for a low-protein diet is: A. Protein breaks down into blood urea nitrogen and metabolic waste. NCLEX PN EXAM 2023 QUESTIONS AND ANSWERS WITH EXPLANATIONS A+ SUCCESS ASSURED B. High protein increases the sodium and potassium levels. NCLEX PN EXAM 2023 QUESTIONS AND ANSWERS WITH EXPLANATIONS A+ SUCCESS ASSURED Answer B: Because the aorta is clamped during surgery, the blood supply to the kidneys is impaired. This can result in renal damage. A urinary output of 20mL is oliguria. In answer A, the pedal pulses that are thready and regular are within normal limits. For answer C, it is desirable for the client’s blood pressure to be slightly low after surgical repair of an aneurysm. The oxygen saturation of 97% in answer D is within normal limits and, therefore, incorrect.  The nurse is teaching the client regarding use of sodium warfarin. Which statement made by the client would require further teaching? A. “I will have blood drawn every month.” B. “I will assess my skin for a rash.” C. “I take aspirin for a headache.” D. “I will use an electric razor to shave.” Answer C: The client taking an anticoagulant should not take aspirin because it will further thin the blood. He should return to have a Protime drawn for bleeding time, report a rash, and use an electric razor. Therefore, answers A, B, and D are incorrect.  A client with a femoral popliteal bypass graft is assigned to a semiprivate room. The most suitable roommate for this client is the client with: A. Hypothyroidism B. Diabetic ulcers C. Ulcerative colitis D. Pneumonia Answer A: The best roommate for the post-surgical client is the client with hypothyroidism. This client is sleepy and has no infectious process. Answers B, C, and D are incorrect because the client with a diabetic ulcer, ulcerative colitis, or pneumonia can transmit infection to the post-surgical client.  The nurse has just received shift report and is preparing to make rounds. Which client should be seen first? NCLEX PN EXAM 2023 QUESTIONS AND ANSWERS WITH EXPLANATIONS A+ SUCCESS ASSURED A. The client who has a history of a cerebral aneurysm with an oxygen saturation rate of 99% B. The client who is three days post–coronary artery bypass graft with a temperature of 100.2°F C. The client who was admitted 1 hour ago with shortness of breath D. The client who is being prepared for discharge following a femoral popliteal bypass graft Answer C: The client admitted 1 hour ago with shortness of breath should be seen first because this client might require oxygen therapy. The client in answer A with a low-grade temperature can be assessed after the client with shortness of breath. The client in answer B can also be seen later. This client will have some inflammatory process after surgery, so a temperature of 100.2°F is not unusual. The low-grade temperature should be re-evaluated in 1 hour. The client in answer D can be reserved for later.  The doctor has ordered antithrombolic stockings to be applied to the legs of the client with peripheral vascular disease. The nurse knows that the proper method of applying the stockings is: A. Before rising in the morning B. With the client in a standing position C. After bathing and applying powder D. Before retiring in the evening Answer A: The best time to apply antithrombolytic stockings is in the morning before rising. If the doctor orders them later in the day, the client should return to bed, wait 30 minutes, and apply the stockings. Answers B, C, and D are incorrect because there is likely to be more peripheral edema if the client is standing or has just taken a bath; before retiring in the evening is wrong because, late in the evening, more peripheral edema will be present.  The nurse is preparing a client with an axillo-popliteal bypass graft for discharge. The client should be taught to avoid: A. Using a recliner to rest B. Resting in supine position C. Sitting in a straight chair D. Sleeping in right Sim’s position NCLEX PN EXAM 2023 QUESTIONS AND ANSWERS WITH EXPLANATIONS A+ SUCCESS ASSURED Answer C: The client with a femoral popliteal bypass graft should avoid activities that can occlude the femoral artery graft. Sitting in the straight chair and wearing tight clothes are prohibited for this reason. Resting in a supine position, resting in a recliner, or sleeping in right Sim’s are allowed, as stated in answers A, B, and D. NCLEX PN EXAM 2023 QUESTIONS AND ANSWERS WITH EXPLANATIONS A+ SUCCESS ASSURED Answer C: Children at age 2 can reach for objects that they desire and use NCLEX PN EXAM 2023 QUESTIONS AND ANSWERS WITH EXPLANATIONS A+ SUCCESS ASSURED simple words such as cookie to express what they want. They already understand “yes” and “no,” so answer A is incorrect. Simple language patterns begin to develop after this age, even though children at this age might understand some words; therefore, answer B is not a good choice. Later, at about age 3 or 4, they begin to ask “Why?,” making answer D incorrect.  In terms of cognitive development, a 2-year-old would be expected to: A. Think abstractly B. Use magical thinking C. Understand conservation of matter D. See things from the perspective of others Answer B: A 2-year-old is expected only to use magical thinking, such as believing that a toy bear is a real bear. Answers A, C, and D are not expected until the child is much older. Abstract thinking, conservation of matter, and the ability to look at things from the perspective of others are not skills for small children.  The nurse is ready to begin an exam on a 9-month-old infant. The child is sitting in his mother’s lap. What should the nurse do first? A. Check the Babinski reflex B. Listen to the heart and lung sounds C. Palpate the abdomen D. Check tympanic membranes Answer B: The first action that the nurse should take when beginning to examine the infant is to listen to the heart and lungs. If the nurse elicits the Babinski reflex, palpates the abdomen, or looks in the child’s ear first, the child will begin to cry and it will be difficult to obtain an objective finding while listening to the heart and lungs. Therefore, answers A, C, and D are incorrect.  Which of the following examples represents parallel play? A. Jenny and Tommy share their toys. B. Jimmy plays with his car beside Mary, who is playing with her doll. NCLEX PN EXAM 2023 QUESTIONS AND ANSWERS WITH EXPLANATIONS A+ SUCCESS ASSURED C. Kevin plays a game of Scrabble with Kathy and Sue. D. Mary plays with a handheld game while sitting in her mother’s lap. Answer B: Parallel play is play that is demonstrated by two children playing side by side but not together. The play in answers A and C is participative play because the children are playing together. The play in answer D is solitary play because the mother is not playing with Mary.  Assuming that all have achieved normal cognitive and emotional development, which of the following children is at greatest risk for accidental poisoning? A. A 6-month-old B. A 4-year-old C. A 10-year-old D. A 13-year-old Answer B: The 4-year-old is more prone to accidental poisoning because children at this age are much more mobile and this makes them more likely to ingest poisons than the other children. Answers A, C, and D are incorrect because the 6-month-old is still too small to be extremely mobile, the 10- year-old has begun to understand risk, and the 13-year-old is also aware of the risks of poisoning and is less likely to ingest poisons than the 4-year- old.  An important intervention in monitoring the dietary compliance of a client with bulimia is: A. Allowing the client privacy during mealtimes B. Praising her for eating all her meals C. Observing her for 1–2 hours after meals D. Encouraging her to choose foods she likes and to eat in moderation Answer C: To prevent the client from inducing vomiting after eating, the client should be observed for 1–2 hours after meals. Allowing privacy as stated in answer A will only give the client time to vomit. Praising the client for eating all of a meal does not correct the psychological aspects of the disease; thus, answer B is incorrect. Encouraging the client to choose favorite foods might increase stress and the chance of choosing foods that are low in