NCLEX-PN QUESTIONS & ANSWERS 2024, Exams of Nursing

Download NCLEX-PN QUESTIONS & ANSWERS 2024 and more Exams Nursing in PDF only on Docsity! NCLEX-PN QUESTIONS & ANSWERS MADE INCREDIBLY EASY!: 3,000 + QUESTIONS! A 40-year-old client is admitted to the hospital for alcohol abuse for the third time in the past 9 months. The health care team recommends rehabilitative treatment for this client. Why was this treatment recommended? 1. It's the only option for controlling alcohol consumption. 2. It helps the client identify a new group of friends. 3. It helps the client understand the effects of alcohol on his body. 4. It helps the client identify the relationship between his problems and alcohol consumption.,Correct Answer: 4 RATIONALES: The purpose of rehabilitative treatment in alcoholism is to help the client identify the relationship between his problems and his alcohol consumption. Rehabilitative treatment promotes abstinence, not limiting or controlling consumption. It isn't intended to help the client identify a new group of friends or understand the effects of alcohol on his body. A 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 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 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 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 A client comes to the emergency department complaining of headache, malaise, chills, fever, and a stiff neck. Vital sign assessment reveals a temperature elevation, increased heart and respiratory rates, and normal blood pressure. On physical examination, the nurse notes confusion, a petechial rash, nuchal rigidity, Brudzinski's sign, and Kernig's sign. What does Brudzinski's sign indicate? 1. Increased intracranial pressure (ICP) 2. Cerebral edema 3. Low cerebrospinal fluid (CSF) pressure 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. 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? 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. A client is admitted to the health care facility with bowel obstruction secondary to colon cancer. The nurse obtains a health history, measures vital signs, and auscultates for bowel sounds. Which step of the nursing process is the nurse performing? 1. Planning 2. Data collection 3. Evaluation 4. Implementation,Correct Answer: 2 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. 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 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 3. Increased urine output 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. 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. The ligamentum flavum and the area between the subarachnoid space and the dura mater are inappropriate injection sites. 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 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. 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 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 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. 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. A client with hyperemesis gravidarum is on a clear liquid diet. The nurse should serve this client: 1. milk and ice pops. 2. decaffeinated coffee and scrambled eggs. 3. tea and gelatin dessert. 4. apple juice and oatmeal.,Correct Answer: 3 RATIONALES: A clear liquid diet consists of foods that are clear liquids at room temperature or body temperature, such as ice pops, regular or decaffeinated coffee and tea, gelatin desserts, carbonated beverages, and clear juices. Milk, pasteurized eggs, egg substitutes, and oatmeal are part of a full liquid diet. 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 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. 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. 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. "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. A hospitalized client asks the nurse for "something for pain." Which information is most important for the nurse to gather before administering the medication? Select all that apply: 1. Administration time of the last dose 2. Client's pain level on a scale of 1 to 10 3. Type of medication the client has been taking 4. Client's reaction to the previous dose 5. Client's most current height and weight 6. Effectiveness of prior dose of medication,Correct Answer: 1,2,3,4,6 RATIONALES: The nurse needs to know when the last dose was administered. Some clients request pain medication earlier than is ordered by the physician. Pain, the fifth vital sign, should be assessed using a pain scale and documented in the nursing notes whenever a pain medication is 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. A man at a pizza parlor verbally confronts the waiter for lack of attentiveness. Later, in the back room, the waiter spits on the man's pizza. This is an example of a behavior typical of which disorder? 1. Obsessive-compulsive 2. Narcissistic 3. Passive-aggressive 4. Dependent,Correct Answer: 3 RATIONALES: This is an example of a negative attitude and passive-aggressive behavior in response to demands for adequate performance. People with this disorder won't confront or discuss issues with others but will go to great lengths to "get even." Obsessive-compulsive disorder involves rituals or rules that interfere with normal functioning. A person with a narcissistic personality has an exaggerated sense of self- worth. A person with a dependent personality is submissive and frequently apologizes and backs down when confronted. A newly hired licensed practical nurse (LPN) is helping the charge nurse admit a client. The charge nurse asks the LPN if she understands the facility's rules of ethical conduct. Which statement by the LPN indicates the need for further teaching? 1. "I make sure that I do everything in my client's best interest." 2. "I maintain client confidentiality at all times." 3. "I always support the Patient's Bill of Rights." 4. "I don't discuss advance directives unless the client initiates the conversation.",Correct Answer: 4 RATIONALES: The law mandates that health care agencies ask all clients if they have an advance directive. Therefore, the LPN must address this question regardless of whether the client initiates a conversation about it. Nurses must always act in the best interest of their clients, maintain confidentiality, and support the Patient's Bill of Rights. 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. Not answering the nurse's questions 4. Not crying when moved,Correct Answer: 4 RATIONALES: Not crying when moved most strongly suggests child abuse. A victim of child abuse typically doesn't complain of pain, even with obvious injuries, for fear of further displeasing the abuser. Trying to sit up on the stretcher is a typical client response. Trying to move away from the nurse indicates fear of strangers, which is normal in a toddler. Difficulty answering the nurse's questions is expected in a toddler because of poorly developed cognitive skills. A 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, the nurse should check for breathing and, if indicated, initiate rescue breathing. 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. 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. 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. 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. As an adolescent is receiving care, he's inadvertently injured with a warm compress. The nurse completes an incident report based on the knowledge that identification of which of the following is a goal of the report? 1. To reprimand the involved staff members for their actions 3. decreasing potassium excretion. 4. stimulating or hindering micturition.,Correct Answer: 4 RATIONALES: Anxiety may stimulate or hinder micturition. Its most noticeable effect is to cause frequent voiding and urinary urgency. However, when anxiety leads to generalized muscle tension, it may hinder urination because the perineal muscles must relax to complete micturition. Anxiety doesn't slow the glomerular filtration rate, increase sodium resorption, or decrease potassium excretion. Following a small-bowel resection, a client develops fever and anemia. The surface surrounding the surgical wound is warm to the touch and necrotizing fasciitis is suspected. Another manifestation that would most suggest necrotizing fasciitis is: 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. 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 energy and calories, the nurse should encourage the client to eat high-carbohydrate foods. In a client who's predisposed to bipolar disorder, a bipolar episode might be triggered by: 1. hypothyroidism. 2. hyperglycemia. 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. 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 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. One aspect of implementation related to drug therapy is: 1. developing a content outline. 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. The nurse assesses a client who gave birth 24 hours earlier. Which of the following findings reveals the need for further evaluation? 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 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 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 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. 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. 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. 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. The nurse is collecting data on an 8-month-old infant during a wellness checkup. Which of the following is a normal developmental task for an infant this age? 1. Sitting without support 2. Saying two words 3. Feeding himself with a spoon 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 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 RATIONALES: When assessing skin integrity, the overall risk potential for developing pressure ulcers takes priority. Overall risk encompasses existing pressure ulcers as well as potential areas for development of pressure ulcers. Family history isn't important when assessing skin integrity. The nurse is 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 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 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. Rapidly instill a stream of irrigating solution into the wound.,Correct Answer: 1 RATIONALES: To wash away tissue debris and drainage effectively, the nurse should irrigate the wound until the solution becomes clear or all of the solution has been used. After the irrigation, the nurse should dry the area around the wound; moistening it promotes microorganism growth and skin irritation. When the area is dry, the nurse should apply a sterile dressing, rather than awet-to-dry dressing. The nurse always should instill the irrigating solution gently; rapid or forceful instillation can damage tissues. 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. 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. 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. The physician prescribes furosemide (Lasix), 2 mg/kg P.O., as a one-time dose for an infant with fluid overload. The infant's documented weight is 14 lb. The oral solution contains 10 mg/ml. How many milliliters of solution should the nurse administer?,Correct Answer: 1.3 RATIONALES: To perform the dosage calculation, first convert the infant's weight from pounds to kilograms by setting up the following proportion: 2.2 lb/1 kg = 14 lb/X X = 6.4 kg. Then perform the following calculation to determine the total dose prescribed: 2 mg/kg = X/6.4 kg X = 12.8 mg. Then set up the following proportion to determine the volume of medication to administer: 10 mg/ml = 12.8 mg/X X = 1.3 ml. 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. 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. 3. Alprazolam (Xanax) and phenobarbital (Luminal) 4. Clozapine (Clozaril) and amitriptyline (Elavil),Correct Answer: 3 RATIONALES: Both benzodiazepines (such as alprazolam) and barbiturates (such as phenobarbital) are addictive, controlled substances. None of the other drugs listed are addictive substances. 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. 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. Which nursing action is essential when providing continuous enteral feeding? 1. Elevating the head of the bed at least 30 degrees 2. Positioning the client on the left side 3. Warming the formula before administering it 4. Hanging a full day's worth of formula at one time,Correct Answer: 1 RATIONALES: Elevating the head of the bed at least 30 degrees during enteral feeding minimizes the risk of aspiration and allows the formula to flow into the client's intestines. When such elevation is contraindicated, the client should be positioned on the right side. The nurse should give enteral feedings at room temperature to minimize GI distress. To limit microbial growth, the nurse should hang only the amount of formula that can be infused in 8 hours. Which psychological or personality factor is likely to predispose an individual to medication abuse? 1. Low self-esteem and unresolved rage 2. Desire to inflict pain upon one's self 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 safety device is most restrictive for a client with dementia? 1. Walker 2. Childproof locks on cabinets and doors 3. Electronic monitoring system