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NCLEX-PN 3000 Questions With accurate answers, Rated A+. 2022. Rationale answers, GradeD A+

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NCLEX-PN 3000 Questions With accurate answers, Rated A+. 2022 The parent of a preschooler with chickenpox asks the nurse about measures to make the child comfortable. The nurse instructs the pare... nt to avoid administering aspirin or any other product that contains salicylates. When given to children with chickenpox, aspirin has been linked to which disorder? 1. Guillain-Barré syndrome 2. Rheumatic fever 3. Reye's syndrome 4. Scarlet fever - ✔✔Correct Answer: 3 RATIONALES: Research shows a correlation between the use of aspirin during chickenpox and the development of Reye's syndrome (a disorder characterized by brain and liver toxicity). Therefore, the nurse should instruct the parents to avoid administering aspirin or other products that contain salicylates and to consult the physician or pharmacist before administering any medication to a child with chickenpox. No research has found a link between aspirin use, chickenpox, and the development of Guillain-Barré syndrome, rheumatic fever, or scarlet fever. A client is to have an epidural block to relieve labor pain. The nurse anticipates that the anesthesiologist will inject the anesthetic agent into the: 1. subarachnoid space. 2. area between the subarachnoid space and the dura mater. 3. area between the dura mater and the ligamentum flavum. 4. ligamentum flavum. - ✔✔Correct Answer: 3 RATIONALES: For an epidural block, the nurse should anticipate that the anesthesiologist will inject a local anesthetic agent into the epidural space, located between the dura mater and the ligamentum flavum in the lumbar region of the spinal column. When administering a spinal block, the anesthesiologist injects the anesthetic agent into the subarachnoid space. The ligamentum flavum and the area between the subarachnoid space and the dura mater are inappropriate injection sites. The physician prescribes penicillin potassium oral suspension 56 mg/kg/day in four divided doses for a client with anorexia nervosa who weighs 25 kg. The medication dispensed by the pharmacy contains a dosage strength of 125 mg/5 ml. How many milliliters of solution should the nurse administer with each dose? - ✔✔Correct Answer: 14 RATIONALES: To determine the total daily dosage, set up the following proportion: 25 kg/X = 1 kg/56 mg X = 1,400 mg. Next, divide the daily dosage by four doses to determine the dose to administer every 6 hours: X = 1,400 mg/4 doses X = 350 mg/dose. The adolescent should receive 350 mg every 6 hours. Lastly, calculate the volume to give for each dose by setting up this proportion: X/350 mg = 5 ml/125 mg X = 14 ml. The nurse must irrigate a gaping abdominal incision with sterile normal saline, using a piston syringe. How should the nurse proceed? 1. Irrigate continuously until the solution becomes clear or all of the solution has been used. 2. Moisten the area around the wound with normal saline after the irrigation. 3. Apply a wet-to-dry dressing to the wound after the irrigation. 4. Rapidly instill a stream of irrigating solution into the wound. - ✔✔Correct Answer: 1 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. 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 2. To identify the learning needs of staff to prevent incident recurrences 3. To reprimand the nurse-manager responsible for the unit 4. To hold people accountable for their actions - ✔✔Correct Answer: 2 RATIONALES: The purpose of an incident report is threefold: to identify ways to prevent incident recurrences, to identify patterns of care problems, and to identify facts surrounding each incident. Incident reports aren't used to hold people accountable for their actions, to punish those involved in the incident, or to punish the nurse-manager responsible for the unit. As a client progresses through pregnancy, she develops constipation. What is the primary cause of this problem during pregnancy? 1. Decreased appetite 2. Inadequate fluid intake 3. Prolonged gastric emptying 4. Reduced intestinal motility - ✔✔Correct Answer: 4 RATIONALES: During pregnancy, hormonal changes and mechanical pressure reduce motility in the small intestine, enhancing water absorption and promoting constipation. Although decreased appetite, inadequate fluid intake, and prolonged gastric emptying may contribute to constipation, they aren't the primary cause. An adolescent with type 1 diabetes mellitus is experiencing a growth spurt. Which treatment approach would be most effective for this client? 1. Administering insulin once per day 2. Administering multiple doses of insulin 3. Limiting dietary fat intake 4. Substituting an oral antidiabetic agent for insulin - ✔✔Correct Answer: 2 RATIONALES: During an adolescent growth spurt, a regimen of multiple insulin doses achieves better control of the blood glucose level because it more closely simulates endogenous insulin release. A single daily dose of insulin wouldn't control this client's blood glucose level as effectively. Limiting dietary fat intake wouldn't help the body use glucose at the cellular level. An adolescent with type 1 diabetes mellitus doesn't produce insulin and therefore can't receive an oral antidiabetic agent instead of insulin. A client is admitted to the health care facility with bowel obstruction secondary to colon cancer. The nurse obtains a health history, measures vital signs, and auscultates for bowel sounds. Which step of the nursing process is the nurse performing? 1. Planning 2. Data collection 3. Evaluation 4. Implementation - ✔✔Correct Answer: 2 RATIONALES: During the data collection step of the nursing process, the nurse obtains the client's health history, measures vital signs, and performs a physical examination to gather data for use in formulating the nursing diagnoses. During the planning step, the nurse designs methods to help resolve client problems and meet client needs. During evaluation, the nurse determines the effectiveness of nursing interventions in achieving client goals. During implementation, the nurse takes actions to meet the client's needs. The physician prescribes meperidine (Demerol), 1.1 mg/kg I.M., for a 16-month-old child who has just had abdominal surgery. When administering this drug, the nurse should use a needle of which size? 1. 18G 2. 20G 3. 23G 4. 27G - ✔✔Correct Answer: 3 RATIONALES: For an infant, the nurse should use a needle with the smallest appropriate gauge for the medication to be given. For an I.M. injection of meperidine, a 25G to 22G needle is appropriate. Which finding in a neonate suggests hypothermia? 1. Bradycardia 2. Hyperglycemia 3. Metabolic alkalosis 4. Shivering - ✔✔Correct Answer: 1 RATIONALES: Neonates who are hypothermic typically develop bradycardia. Hypoglycemia, not hyperglycemia, and metabolic acidosis, not metabolic alkalosis, are also seen in neonates with hypothermia. Neonates typically don't shiver. Initial client assessment information includes blood pressure 160/110 mm Hg, pulse 88 beats/minute, respiratory rate 22 breaths/minute, and reflexes +3/+4 with 2 beat clonus. Urine specimen reveals +3 protein, negative sugar and ketones. Based on these findings, the nurse would expect the client to have which complaints? 1. Headache, blurred vision, and facial and extremity swelling 2. Abdominal pain, urinary frequency, and pedal edema 3. Diaphoresis, nystagmus, and dizziness 4. Lethargy, chest pain, and shortness of breath - ✔✔Correct Answer: 1 RATIONALES: The client is exhibiting signs of preeclampsia. In addition to hypertension and hyperreflexia, most preeclamptic clients have edema. Headache and blurred vision are indications of the effects of the hypertension. Abdominal pain, urinary frequency, diaphoresis, nystagmus, dizziness, lethargy, chest pain, and shortness of breath are inconsistent with a diagnosis of preeclampsia. The nurse is performing a baseline assessment of a client's skin integrity. Which of the following is a key assessment parameter? 1. Family history of pressure ulcers 2. Presence of existing pressure ulcers 3. Potential areas of pressure ulcer development 4. Overall risk of developing pressure ulcers - ✔✔Correct Answer: 4 RATIONALES: When assessing skin integrity, the overall risk potential for developing pressure ulcers takes priority. Overall risk encompasses existing pressure ulcers as well as potential areas for development of pressure ulcers. Family history isn't important when assessing skin integrity. The nurse is preparing to boost a client up in bed. She instructs the client to use the overbed trapeze. Which risk factor for pressure ulcer development is the nurse reducing by instructing the client to move in this manner? 1. Friction 2. Impaired circulation 3. Localized pressure 4. Shearing forces - ✔✔Correct Answer: 4 RATIONALES: Using a trapeze reduces shearing forces (opposing forces that cause layers of skin to move over each other, stretching and tearing capillaries and, eventually, resulting in necrosis), which increase the risk of pressure ulcer development. They can occur as clients slide down in bed or when they're pulled up in bed. To reduce shearing forces, the nurse should instruct the client to use an overbed trapeze, place a draw sheet under the client to move the client up in bed, and keep the head of the bed no higher than 30 degrees. The risks of friction, impaired circulation, and localized pressure aren't decreased with trapeze use. A geriatric client with Alzheimer's disease has been living with his grown child's family for the last 6 months. He wanders at night and needs help with activities of daily living. Which statement by his child suggests that the family is successfully adjusting to this living arrangement? 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. 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: 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. 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 diagnosis.) The preferred choice is tPA. The client doesn't exhibit symptoms that indicate the use of lidocaine. Stress testing shouldn't be performed during the acute phase of an MI, but it may be ordered before discharge. Serial cardiac biomarkers, not serial liver enzymes, would be ordered for this client. A nurse's neighbor complains of severe right flank pain. She explains that it began during the night, but she was able to take acetaminophen (Tylenol) and return to bed. When she awoke, the pain increased in intensity. How should the nurse intervene? 1. Explain that she can't give medical advice. 2. Inform the neighbor that she might require surgery. 3. Advise the neighbor to seek medical attention. 4. Tell the neighbor that she'll be fine because she was able to get through the night. - ✔✔Correct Answer: 3 RATIONALES: The nurse should advise the neighbor to seek medical attention. Explaining that she can't give medical advice might cause a delay in treatment. It's beyond the nurse's scope of practice to suggest that the neighbor might need surgery. Telling the neighbor she'll be fine might also delay treatment, and it isn't a professional response. 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. One day after being admitted with bipolar disorder, a client becomes verbally aggressive during a group therapy session. Which response by the nurse would be therapeutic? 1. "You're behaving in an unacceptable manner, and you need to control yourself." 2. "If you continue to talk like that, no one will want to be around you." 3. "You're disturbing the other clients. I'll walk with you around the patio to help you release some of your energy." 4. "You're scaring everyone in the group. Leave the room immediately." - ✔✔Correct Answer: 3 RATIONALES: This response shows that the nurse finds the client's behavior unacceptable, yet still regards the client as worthy of help. The other options give the false impression that the client is in control of the behavior; the client hasn't been in treatment long enough to control the behavior. A client comes to the emergency department complaining of headache, malaise, chills, fever, and a stiff neck. Vital sign assessment reveals a temperature elevation, increased heart and respiratory rates, and normal blood pressure. On physical examination, the nurse notes confusion, a petechial rash, nuchal rigidity, Brudzinski's sign, and Kernig's sign. What does Brudzinski's sign indicate? 1. Increased intracranial pressure (ICP) 2. Cerebral edema 3. Low cerebrospinal fluid (CSF) pressure 4. Meningeal irritation - ✔✔Correct Answer: 4 RATIONALES: Brudzinski's sign indicates meningeal irritation, as in meningitis. Other signs of meningeal irritation include nuchal rigidity and Kernig's sign. Brudzinski's sign doesn't indicate increased ICP, cerebral edema, or low CSF pressure. During a routine examination, the nurse notes that the client seems unusually anxious. Anxiety can affect the genitourinary system by: 1. slowing the glomerular filtration rate. 2. increasing sodium resorption. 3. decreasing potassium excretion. 4. stimulating or hindering micturition. - ✔✔Correct Answer: 4 RATIONALES: Anxiety may stimulate or hinder micturition. Its most noticeable effect is to cause frequent voiding and urinary urgency. However, when anxiety leads to generalized muscle tension, it may hinder urination because the perineal muscles must relax to complete micturition. Anxiety doesn't slow the glomerular filtration rate, increase sodium resorption, or decrease potassium excretion. The nurse is advising a mother about foods to avoid to prevent choking in her toddler. Which foods should she include in her instruction? 1. Small pieces of banana 2. Large, round chunks of meat such as hot dog 3. Cooked vegetables such as lima beans and corn 4. Frozen desserts such as ice cream - ✔✔Correct Answer: 2 RATIONALES: The nurse should advise the mother to avoid giving her child large, round chunks of meat such as hot dog. The mother can safely give the toddler small pieces of banana; cooked vegetables, such as lima beans and corn; and frozen desserts such as ice cream. A client with a history of Addison's disease and flulike symptoms accompanied by nausea and vomiting over the past week is brought to the facility. The client's wife reports that she noticed that he acted confused and was extremely weak when he woke up in the morning. The client's blood pressure is 90/58 mm Hg, his pulse is 116 beats/minute, and his temperature is 101° F (38.3° C). A diagnosis of acute adrenal insufficiency is made. Which of the following would the nurse expect to administer by I.V. infusion? 1. Insulin 2. Hydrocortisone 3. Potassium 4. Hypotonic saline - ✔✔Correct Answer: 2 RATIONALES: Emergency treatment for acute adrenal insufficiency (addisonian crisis) is I.V. infusion of hydrocortisone and saline solution. The client is usually given 100 mg of hydrocortisone in normal saline every 6 hours until his blood pressure returns to normal. Insulin isn't indicated in this situation because adrenal insufficiency is usually associated with hypoglycemia. Potassium isn't indicated because these clients are usually hyperkalemic. The client needs normal — not hypotonic — saline solution. A toddler is diagnosed with a dislocated right shoulder and a simple fracture of the right humerus. Which behavior most stronglysuggests that the child's injuries stem from abuse? 1. Trying to sit up on the stretcher 2. Trying to move away from the nurse 3. Not answering the nurse's questions 4. Not crying when moved - ✔✔Correct Answer: 4 RATIONALES: Not crying when moved most strongly suggests child abuse. A victim of child abuse typically doesn't complain of pain, even with obvious injuries, for fear of further displeasing the abuser. Trying to sit up on the stretcher is a typical client response. Trying to move away from the nurse indicates fear of strangers, which is normal in a toddler. Difficulty answering the nurse's questions is expected in a toddler because of poorly developed cognitive skills. A client is scheduled for an excretory urography at 10 a.m. An order states to insert a saline lock I.V. device at 9:30 a.m.. The client requests a local anesthetic for the I.V. procedure and the physician orders lidocaine-prilocaine cream (EMLA cream). The nurse should apply the cream at: 1. 7:30 a.m. 2. 6:30 a.m. 3. 9 a.m. 4. 9:30 a.m. - ✔✔Correct Answer: 1 RATIONALES: It takes up to 2 hours for lidocaine-prilocaine cream (EMLA cream) reach its maximum effectiveness. Therefore, if the cannulation is scheduled for 9:30 a.m., EMLA cream should be applied at 7:30 a.m. Applying EMLA at 6:30 a.m. is too early. The other time options are too late for the local anesthetic to be effective. 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 [Show More]

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