NCLEX Exam Practice Question of the Week 07/13
Question: The doctor has indicated that ampicillin and gentamicin are to be given piggyback in the same hour, every 6 hours (12-6-12-6). How would the nurse administer these drugs?
1. Give both drugs together IV push.
2. Give each drug separately, flushing between drugs
3. Retrograde both drugs into the tubing
4. Give one drug every 4 hours and one every 6 hours.
1. Give both drugs together IV push.
2. Give each drug separately, flushing between drugs
3. Retrograde both drugs into the tubing
4. Give one drug every 4 hours and one every 6 hours.
Rationale: Only one antibiotic should be administered at a time; therefore if the medications are given during the same hour, the IV tubing will need to be flushed between administrations. Both drugs should be administered at the time ordered.
NCLEX Exam Practice Question of the Week 07/20
Question: Which structural defect should a nurse suspect in a newborn with excessive salivation and drooling, accompanied by coughing and choking?
1. Cleft lip
2. Cleft palate
3. Pyloric stenosis
4. Tracheoesophageal fistula
1. Cleft lip
2. Cleft palate
3. Pyloric stenosis
4. Tracheoesophageal fistula
Answer: 4
Rationale: Tracheoesophageal fistula is an opening connecting the trachea and the esophagus. Because of ineffective swallowing ability, saliva and secretions appear in the mouth and around the lips. Coughing and choking occur for the same reason, usually after attempting to eat. Cleft lip (1) and cleft palate (2) are structural defects in the upper lip and palate and may cause coughing and difficulty swallowing but not excessive salivation and drooling. Pyloric stenosis (3) manifests as projectile vomiting caused by a narrowing of the pylorus.
Rationale: Tracheoesophageal fistula is an opening connecting the trachea and the esophagus. Because of ineffective swallowing ability, saliva and secretions appear in the mouth and around the lips. Coughing and choking occur for the same reason, usually after attempting to eat. Cleft lip (1) and cleft palate (2) are structural defects in the upper lip and palate and may cause coughing and difficulty swallowing but not excessive salivation and drooling. Pyloric stenosis (3) manifests as projectile vomiting caused by a narrowing of the pylorus.
NCLEX Exam Practice Question of the Week - 07/27/11
Question: The nurse is evaluating the status of the client who had a craniotomy 3 days ago. The nurse would suspect that the client is developing meningitis as a complication of surgery if the client exhibits:
1. A negative Kernig sign
2. Absence of nuchal rigidity
3. A positive Brudzinski sign
4. A Glasgow Coma Scale score of 15
1. A negative Kernig sign
2. Absence of nuchal rigidity
3. A positive Brudzinski sign
4. A Glasgow Coma Scale score of 15
Answer: 3
Rationale: Signs of meningeal irritation compatible with meningitis include nuchal rigidity, a positive Brudzinski sign, and positive Kernig sign. Nuchal rigidity is characterized by a stiff neck and soreness, which is especially noticeable when the neck is flexed. Kernig’s sign is positive when the client feels pain and spasm of the hamstring muscles when the leg is fully flexed at the knee and hip. Brudzinski’s sign is positive when the client flexes the hips and knees in response to the nurse gently flexing the head and neck onto the chest. A Glasgow Coma Scale score of 15 is a perfect score and indicates that the client is awake and alert, with no neurological deficits.
Rationale: Signs of meningeal irritation compatible with meningitis include nuchal rigidity, a positive Brudzinski sign, and positive Kernig sign. Nuchal rigidity is characterized by a stiff neck and soreness, which is especially noticeable when the neck is flexed. Kernig’s sign is positive when the client feels pain and spasm of the hamstring muscles when the leg is fully flexed at the knee and hip. Brudzinski’s sign is positive when the client flexes the hips and knees in response to the nurse gently flexing the head and neck onto the chest. A Glasgow Coma Scale score of 15 is a perfect score and indicates that the client is awake and alert, with no neurological deficits.
NCLEX Exam Practice Question of the Week - 08/03/11
Question: When a recently hospitalized client has a tentative diagnosis of opioid addiction, the nurse should assess the client for signs and symptoms related to opioid withdrawal. List them in the order that they will occur as the client progresses through withdrawal.
1. Runny nose
2. Muscle twitching
3. Return of appetite
4. Flulike syndromes
1. Runny nose
2. Muscle twitching
3. Return of appetite
4. Flulike syndromes
Answer: 1, 2, 4, 3
Rationale: When opioids, which are CNS depressants, are withdrawn initially the client will experience a runny nose (rhinorrhea), tearing of the eyes (lacrimation), diaphoresis, yawning, and irritability. As withdrawal progresses a rebound hyperexcitability precipitates muscle twitching, restlessness, hypertension, tachycardia, temperature irregularities, tremors, and loss of appetite. Finally, flulike symptoms, insomnia and yawning occur. Once withdrawal is complete the appetite returns, vital signs become stable, and other withdrawal signs and symptoms subside and eventually disappear.
Rationale: When opioids, which are CNS depressants, are withdrawn initially the client will experience a runny nose (rhinorrhea), tearing of the eyes (lacrimation), diaphoresis, yawning, and irritability. As withdrawal progresses a rebound hyperexcitability precipitates muscle twitching, restlessness, hypertension, tachycardia, temperature irregularities, tremors, and loss of appetite. Finally, flulike symptoms, insomnia and yawning occur. Once withdrawal is complete the appetite returns, vital signs become stable, and other withdrawal signs and symptoms subside and eventually disappear.
NCLEX Exam Practice Question of the Week - 08/10/11
Question: After a grand mal seizure, what nursing action is the highest priority?
1. Loosen or remove constricting clothing and protect client from injuring himself or herself.
2. Maintain a patent airway by turning the client on his side and suctioning, if necessary.
3. Remain with the client and administer anticonvulsant medications as ordered by the physician.
4. Describe and record events before the onset of the seizure, during the seizure, and after the seizure.
1. Loosen or remove constricting clothing and protect client from injuring himself or herself.
2. Maintain a patent airway by turning the client on his side and suctioning, if necessary.
3. Remain with the client and administer anticonvulsant medications as ordered by the physician.
4. Describe and record events before the onset of the seizure, during the seizure, and after the seizure.
Answer: 2
Rationale: The priority after a grand mal seizure is to maintain a patent airway. The question is asking for a nursing intervention after the seizure is over. The clothes should be loosened so that they do not constrict the client. The nurse may need to remain with the client, and the events of the seizure need to be recorded, but the priority of this question is the airway.
NCLEX Exam Practice Question of the Week - 08/17
Question: A nurse is caring for a client in labor. The nurse determines that the client is beginning the second stage of labor when which of the following assessments is noted?
1. The contractions are regular.
2. The membranes have ruptured.
3. The cervix is dilated completely.
4. The client begins to expel clear vaginal fluid.
1. The contractions are regular.
2. The membranes have ruptured.
3. The cervix is dilated completely.
4. The client begins to expel clear vaginal fluid.
Answer: 3
Rationale: The second stage of labor begins when the cervix is dilated completely and ends with birth of the neonate. Options 1, 2, and 4 are not specific assessment findings of the second stage of labor and occur in stage 1.
NCLEX Exam Practice Question of the Week 08/24
Question: A nurse expects a child with a diagnosis of reactive attachment disorder to:
1. Have been physically abused
2. Try to cling to the mother on separation
3. Be able to develop just superficial relationships with others
4. Have a more positive relationship with the father than with the mother
1. Have been physically abused
2. Try to cling to the mother on separation
3. Be able to develop just superficial relationships with others
4. Have a more positive relationship with the father than with the mother
Answer:3
Rationale: Children who have experienced attachment difficulties with primary caregivers are not able to trust others and therefore relate superficially. Option 1 is a possibility, but not a necessity for this diagnosis. The child probably will not cling or react when separated from the mother, and attachment will not occur with either parent.
NCLEX Exam Practice Question of the Week 08/31
Question: A client with a diagnosis of acute coronary syndrome is on a cardiac monitor. The nurse interprets the monitor rhythm to be ventricular tachycardia at a rate of 160 beats/min. The client is awake and coherent, and oxygen is being administered at a rate of 6 L/min via a nasal cannula. What is the first nursing action?
1. Immediately defibrillate
2. Administer lidocaine IV push
3. Initiate transvenous pacing
4. Administer adenosine IV push
1. Immediately defibrillate
2. Administer lidocaine IV push
3. Initiate transvenous pacing
4. Administer adenosine IV push
Answer: 2
Rationale: The treatment of choice is lidocaine IV push to attempt to convert the dysrhythmia before it progresses to ventricular fibrillation. Adenosine is given for supraventricular tachycardia. Transvenous pacing is initiated for symptomatic bradycardia or asystole. Defibrillation will be necessary if the client loses consciousness.
Rationale: The treatment of choice is lidocaine IV push to attempt to convert the dysrhythmia before it progresses to ventricular fibrillation. Adenosine is given for supraventricular tachycardia. Transvenous pacing is initiated for symptomatic bradycardia or asystole. Defibrillation will be necessary if the client loses consciousness.
NCLEX Exam Practice Question of the Week - 09/7/11
Question: A client addicted to narcotics has a daily appointment to receive methadone hydrochloride. The nurse understands that methadone:
1. Allows symptom-free detoxification of narcotic addiction.
2. Converts narcotic use from an illicit to a legally controlled drug.
3. Provides postoperative pain control without causing narcotic dependence.
4. Counteracts the depressive effects of long-term opiate use on cardiac muscle.
1. Allows symptom-free detoxification of narcotic addiction.
2. Converts narcotic use from an illicit to a legally controlled drug.
3. Provides postoperative pain control without causing narcotic dependence.
4. Counteracts the depressive effects of long-term opiate use on cardiac muscle.
Answer:2
Rationale:Methadone hydrochloride can be legally dispensed. The strength of the drug is controlled and remains constant from dose to dose, which is uncertain with illicit drugs. The drug dose is very gradually tapered to assist the client in decreasing methadone to a minimal dose. Methadone hydrochloride does not allow for symptom-free detoxification from narcotics (1), is not used for the treatment of postoperative pain (3), or to counteract the depressive effects of long-term opiate use on cardiac muscle (4).
Rationale:Methadone hydrochloride can be legally dispensed. The strength of the drug is controlled and remains constant from dose to dose, which is uncertain with illicit drugs. The drug dose is very gradually tapered to assist the client in decreasing methadone to a minimal dose. Methadone hydrochloride does not allow for symptom-free detoxification from narcotics (1), is not used for the treatment of postoperative pain (3), or to counteract the depressive effects of long-term opiate use on cardiac muscle (4).
NCLEX Exam Practice Question of the Week - 09/14/11
Question: A client who has an above-the-knee amputation is fitted with a prosthesis. The nurse evaluates the client’s response to the prosthesis. Which indicates that the prosthesis fits the residual limb correctly?
1. Absence of phantom limb sensation
2. Uneven wearing down of the heels of the shoes
3. Shrinkage of the end portion of the residual limb
4. Darkened skin areas surrounding the end of the residual limb
1. Absence of phantom limb sensation
2. Uneven wearing down of the heels of the shoes
3. Shrinkage of the end portion of the residual limb
4. Darkened skin areas surrounding the end of the residual limb
Answer:4
Rationale: The even distribution of hemosiderin (iron-rich pigment) in the tissue in response to pressure of the prosthesis indicates a correct fit. Option 1 is not related to the proper fit of a prosthesis. Option 2 indicates that the prosthesis is too long or too short. Option 3 will result in an improper fit.
Rationale: The even distribution of hemosiderin (iron-rich pigment) in the tissue in response to pressure of the prosthesis indicates a correct fit. Option 1 is not related to the proper fit of a prosthesis. Option 2 indicates that the prosthesis is too long or too short. Option 3 will result in an improper fit.
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