NCLEX-PN Questions and Answers with Rationales: Latest Update 2023/2024, Exams of Nursing

Download NCLEX-PN Questions and Answers with Rationales: Latest Update 2023/2024 and more Exams Nursing in PDF only on Docsity! NCLEX-PN QUESTIONS AND ANSWERS WITH RATIONALES LATEST UPDATE 2023/2024 TOP RATED A+ FOR EXCELLENT PASS 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 2. To prevent seizures 3. To inhibit labor 4. To block dopamine receptors ✅Correct Answer: 2 RATIONALES: Magnesium sulfate is given to prevent and control seizures in clients with PIH. Beta-adrenergic blockers (such as propranolol, labetalol, and atenolol) and centrally acting blockers (such as methyldopa) are used to lower blood pressure. Magnesium sulfate has no effect on labor or dopamine receptors. The nurse assesses a client who gave birth 24 hours earlier. Which of the following findings reveals the need for further evaluation? NCLEX-PN QUESTIONS AND ANSWERS WITH RATIONALES LATEST UPDATE 2023/2024 TOP RATED A+ FOR EXCELLENT PASS 1. Chills 2. Scant lochia rubra 3. Thirst and fatigue 4. Temperature of 100.2° F (37.9° C) ✅Correct Answer: 2 RATIONALES: During the early postpartum period, lochia rubra should be moderate to significant. Scant lochia rubra suggests that large clots are blocking the lochial flow. After delivery, vasomotor changes may cause a shaking chill. Thirst, fatigue, and a temperature of up to 100.4° F (38° C) also are common at 24 hours postpartum. The ligamentum flavum and the area between the subarachnoid space and the dura mater are inappropriate injection sites. NCLEX-PN QUESTIONS AND ANSWERS WITH RATIONALES LATEST UPDATE 2023/2024 TOP RATED A+ FOR EXCELLENT PASS 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 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 NCLEX-PN QUESTIONS AND ANSWERS WITH RATIONALES LATEST UPDATE 2023/2024 TOP RATED A+ FOR EXCELLENT PASS 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 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 NCLEX-PN QUESTIONS AND ANSWERS WITH RATIONALES LATEST UPDATE 2023/2024 TOP RATED A+ FOR EXCELLENT PASS 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. Which finding in a neonate suggests hypothermia? 1. Bradycardia 2. Hyperglycemia NCLEX-PN QUESTIONS AND ANSWERS WITH RATIONALES LATEST UPDATE 2023/2024 TOP RATED A+ FOR EXCELLENT PASS 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 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 NCLEX-PN QUESTIONS AND ANSWERS WITH RATIONALES LATEST UPDATE 2023/2024 TOP RATED A+ FOR EXCELLENT PASS 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? 1. "It's difficult dealing with Dad. It's a thankless job." 2. "We had no idea this would be so difficult. It's our cross to bear." 3. "Dad really seems to be making progress. We're hoping he'll be able to move back into his house soon." 4. "Dad has presented many challenges. We have alarms on all the outside doors now. Respite care gives us a break." ✅Correct Answer: 4 RATIONALES: This statement demonstrates a realistic understanding of the client's disorder and effective family coping with the challenges it presents. Options 1 and 2 indicate that the family is having difficulty adjusting. Option 3 suggests that the family is in denial or has an unrealistic view of the prognosis for a client with Alzheimer's disease. NCLEX-PN QUESTIONS AND ANSWERS WITH RATIONALES LATEST UPDATE 2023/2024 TOP RATED A+ FOR EXCELLENT PASS The nurse is assessing an elderly client. When performing the assessment, the nurse should consider that one normal age-related change is: 1. cloudy vision. 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: NCLEX-PN QUESTIONS AND ANSWERS WITH RATIONALES LATEST UPDATE 2023/2024 TOP RATED A+ FOR EXCELLENT PASS 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. A client has a history of chronic undifferentiated schizophrenia. Because she has a history of noncompliance with antipsychotic therapy, she'll receive fluphenazine decanoate (Prolixin Decanoate) injections every 4 weeks. Before discharge, what should the nurse include in her teaching plan? NCLEX-PN QUESTIONS AND ANSWERS WITH RATIONALES LATEST UPDATE 2023/2024 TOP RATED A+ FOR EXCELLENT PASS 1. Asking the physician for droperidol (Inapsine) to control any extrapyramidal symptoms that occur 2. Sitting up for a few minutes before standing to minimize orthostatic hypotension 3. Notifying the physician if her thoughts don't normalize within 1 week 4. Expecting symptoms of tardive dyskinesia to occur and to be transient ✅Correct Answer: 2 RATIONALES: The nurse should teach the client how to manage common adverse reactions, such as orthostatic hypotension and anticholinergic effects. The antipsychotic effects of the drug may take several weeks to appear. Droperidol increases the risk ofextrapyramidal effects when given in conjunction with phenothiazines such as fluphenazine. Tardive dyskinesia is a possible adverse reaction and should be reported immediately. One day after being admitted with bipolar disorder, a client becomes verbally aggressive during a group therapy session. Which response by the nurse would be therapeutic? NCLEX-PN QUESTIONS AND ANSWERS WITH RATIONALES LATEST UPDATE 2023/2024 TOP RATED A+ FOR EXCELLENT PASS 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 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? NCLEX-PN QUESTIONS AND ANSWERS WITH RATIONALES LATEST UPDATE 2023/2024 TOP RATED A+ FOR EXCELLENT PASS 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 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 NCLEX-PN QUESTIONS AND ANSWERS WITH RATIONALES LATEST UPDATE 2023/2024 TOP RATED A+ FOR EXCELLENT PASS 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 2. Trying to move away from the nurse 3. Not answering the nurse's questions NCLEX-PN QUESTIONS AND ANSWERS WITH RATIONALES LATEST UPDATE 2023/2024 TOP RATED A+ FOR EXCELLENT PASS 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 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. NCLEX-PN QUESTIONS AND ANSWERS WITH RATIONALES LATEST UPDATE 2023/2024 TOP RATED A+ FOR EXCELLENT PASS 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? 1. Restricting intake of oral fluids 2. Placing extra blankets on the client's bed 3. Limiting intake of high-carbohydrate foods NCLEX-PN QUESTIONS AND ANSWERS WITH RATIONALES LATEST UPDATE 2023/2024 TOP RATED A+ FOR EXCELLENT PASS 4. Maintaining room temperature in the low-normal range ✅Correct Answer: 4 RATIONALES: Graves' disease causes signs and symptoms of hypermetabolism, such as heat intolerance, diaphoresis, excessive thirst and appetite, and weight loss. To reduce heat intolerance and diaphoresis, the nurse should keep the client's room temperature in the low-normal range. To replace fluids lost via diaphoresis, the nurse should encourage, not restrict, intake of oral fluids. Placing extra blankets on the bed of a client with heat intolerance would cause discomfort. To provide needed energy and calories, the nurse should encourage the client to eat high- carbohydrate foods. A client is admitted with a diagnosis of delusions of grandeur. This diagnosis reflects a belief that he is: 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 NCLEX-PN QUESTIONS AND ANSWERS WITH RATIONALES LATEST UPDATE 2023/2024 TOP RATED A+ FOR EXCELLENT PASS 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. 2. Place a tongue blade in the child's mouth. 3. Remove objects from the child's surroundings. 4. Check the child's breathing. ✅Correct Answer: 3 RATIONALES: During a seizure, the nurse's first priority is to protect the child from injury. To prevent injury caused by uncontrolled movements, the nurse must remove objects from the child's surroundings and pad objects that can't be removed. Restraining the child or placing an object in the child's mouth during a seizure may cause injury. Once the seizure stops, NCLEX-PN QUESTIONS AND ANSWERS WITH RATIONALES LATEST UPDATE 2023/2024 TOP RATED A+ FOR EXCELLENT PASS 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 QUESTIONS AND ANSWERS WITH RATIONALES LATEST UPDATE 2023/2024 TOP RATED A+ FOR EXCELLENT PASS 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 NCLEX-PN QUESTIONS AND ANSWERS WITH RATIONALES LATEST UPDATE 2023/2024 TOP RATED A+ FOR EXCELLENT PASS 2. Red, nodular skin lesions around the thorax 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." NCLEX-PN QUESTIONS AND ANSWERS WITH RATIONALES LATEST UPDATE 2023/2024 TOP RATED A+ FOR EXCELLENT PASS 4. isolate the child with impetigo from other members of the family. ✅Correct Answer: 3 RATIONALES: The spread of childhood infections, including impetigo, can be reduced when children are taught proper hand-washing technique. Because impetigo is spread through direct contact, covering the mouth and nose when sneezing won't prevent its spread. Currently, there is no vaccine to prevent a child from contracting impetigo. Isolating the child with impetigo is unnecessary. A diabetic client develops sinusitis and otitis media accompanied by a temperature of 100.8° F (38.2° C). What effect may these findings have on his need for insulin? 1. They will have no effect. 2. They will decrease the need for insulin. 3. They will increase the need for insulin. NCLEX-PN QUESTIONS AND ANSWERS WITH RATIONALES LATEST UPDATE 2023/2024 TOP RATED A+ FOR EXCELLENT PASS 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 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 NCLEX-PN QUESTIONS AND ANSWERS WITH RATIONALES LATEST UPDATE 2023/2024 TOP RATED A+ FOR EXCELLENT PASS 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 QUESTIONS AND ANSWERS WITH RATIONALES LATEST UPDATE 2023/2024 TOP RATED A+ FOR EXCELLENT PASS 1. Blood glucose level of 200 mg/dl 2. White blood cell (WBC) count of 20,000/mm3 3. Potassium level of 3.8 mEq/L 4. Hematocrit (HCT) of 35% ✅Correct Answer: 2 RATIONALES: An increased WBC count indicates infection, probably resulting from peritonitis, which may have been caused by insertion of the peritoneal catheter into the peritoneal cavity. Peritonitis can cause the peritoneal membrane to lose its ability to filter solutes; therefore, peritoneal dialysis would no longer be a treatment option for this client. Hyperglycemia 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? NCLEX-PN QUESTIONS AND ANSWERS WITH RATIONALES LATEST UPDATE 2023/2024 TOP RATED A+ FOR EXCELLENT PASS 1. Sitting without support 2. Saying two words 3. Feeding himself with a spoon 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. NCLEX-PN QUESTIONS AND ANSWERS WITH RATIONALES LATEST UPDATE 2023/2024 TOP RATED A+ FOR EXCELLENT PASS 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 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. NCLEX-PN QUESTIONS AND ANSWERS WITH RATIONALES LATEST UPDATE 2023/2024 TOP RATED A+ FOR EXCELLENT PASS 2. Respirations 3. Temperature 4. Cardiac rhythm ✅Correct Answer: 4 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 NCLEX-PN QUESTIONS AND ANSWERS WITH RATIONALES LATEST UPDATE 2023/2024 TOP RATED A+ FOR EXCELLENT PASS 3. Reflecting 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 QUESTIONS AND ANSWERS WITH RATIONALES LATEST UPDATE 2023/2024 TOP RATED A+ FOR EXCELLENT PASS 4. rectum. ✅Correct Answer: 2 RATIONALES: The small intestine absorbs products of digestion, completes food digestion, and secretes hormones that help control the secretion of bile, pancreatic juice, and intestinal secretions. The stomach stores, mixes, and liquefies the food bolus into chyme and controls food passage into the duodenum; it doesn't absorb products of digestion. Although the large intestine completes the absorption of water, chloride, and sodium, it plays no part in absorbing food. The rectum is the portion of the large intestine that forms and expels feces from the body; its functions don't include absorption. 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. NCLEX-PN QUESTIONS AND ANSWERS WITH RATIONALES LATEST UPDATE 2023/2024 TOP RATED A+ FOR EXCELLENT PASS 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 QUESTIONS AND ANSWERS WITH RATIONALES LATEST UPDATE 2023/2024 TOP RATED A+ FOR EXCELLENT PASS A 76-year-old client is admitted to a long-term care facility with Alzheimer's- type dementia. The client has been wearing the same dirty clothes for several days. The nurse contacts the family and asks them to bring in clean clothing. Which intervention would bestprevent further regression in the client's personal hygiene? 1. Encouraging the client to perform as much self-care as possible 2. Making the client assume responsibility for physical care 3. Assigning a staff member to take over the client's physical care 4. Accepting the client's desire to go without bathing ✅Correct Answer: 1 RATIONALES: Clients with Alzheimer's-type dementia tend to fluctuate in their capabilities. Encouraging self-care to the extent possible helps increase the client's orientation and promotes a trusting relationship with the nurse. Making the client assume responsibility for physical care is unreasonable. Assigning a staff member to take over the client's physical care restricts the client's independence. Accepting the client's desire to go without bathing promotes poor hygiene. NCLEX-PN QUESTIONS AND ANSWERS WITH RATIONALES LATEST UPDATE 2023/2024 TOP RATED A+ FOR EXCELLENT PASS A client, age 20, is being treated for depression. During a conversation with the nurse, she states that her father raped her when she was 7 years old. She says she has nightmares about the experience and sometimes relives it. She also reveals that she fears older men. The client may be exhibiting signs of: 1. posttraumatic stress disorder (PTSD), delayed onset. 2. multiple personality disorder. 3. anxiety disorder. 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. NCLEX-PN QUESTIONS AND ANSWERS WITH RATIONALES LATEST UPDATE 2023/2024 TOP RATED A+ FOR EXCELLENT PASS 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) 2. pseudoephedrine hydrochloride (Sudafed) 3. guaifenesin (Robitussin) NCLEX-PN QUESTIONS AND ANSWERS WITH RATIONALES LATEST UPDATE 2023/2024 TOP RATED A+ FOR EXCELLENT PASS 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 QUESTIONS AND ANSWERS WITH RATIONALES LATEST UPDATE 2023/2024 TOP RATED A+ FOR EXCELLENT PASS 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 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. NCLEX-PN QUESTIONS AND ANSWERS WITH RATIONALES LATEST UPDATE 2023/2024 TOP RATED A+ FOR EXCELLENT PASS 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 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. NCLEX-PN QUESTIONS AND ANSWERS WITH RATIONALES LATEST UPDATE 2023/2024 TOP RATED A+ FOR EXCELLENT PASS 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 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. NCLEX-PN QUESTIONS AND ANSWERS WITH RATIONALES LATEST UPDATE 2023/2024 TOP RATED A+ FOR EXCELLENT PASS 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. A client with chronic obstructive pulmonary disease, who has been receiving mechanical ventilation for the past 5 days, expresses to a nurse his desire to have treatment withdrawn. Which statement about the client's legal rights is true in this situation? NCLEX-PN QUESTIONS AND ANSWERS WITH RATIONALES LATEST UPDATE 2023/2024 TOP RATED A+ FOR EXCELLENT PASS 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 QUESTIONS AND ANSWERS WITH RATIONALES LATEST UPDATE 2023/2024 TOP RATED A+ FOR EXCELLENT PASS 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 QUESTIONS AND ANSWERS WITH RATIONALES LATEST UPDATE 2023/2024 TOP RATED A+ FOR EXCELLENT PASS 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? 1. Decreased level of consciousness (LOC) 2. Elevated blood pressure NCLEX-PN QUESTIONS AND ANSWERS WITH RATIONALES LATEST UPDATE 2023/2024 TOP RATED A+ FOR EXCELLENT PASS 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 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. 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 NCLEX-PN QUESTIONS AND ANSWERS WITH RATIONALES LATEST UPDATE 2023/2024 TOP RATED A+ FOR EXCELLENT PASS 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 region of the spinal column. When administering a spinal block, the anesthesiologist injects the anesthetic agent into the subarachnoid space. NCLEX-PN QUESTIONS AND ANSWERS WITH RATIONALES LATEST UPDATE 2023/2024 TOP RATED A+ FOR EXCELLENT PASS 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?