NCLEX Exam Practice Question of the Week - 2/8/12
Question: The nurse is assigned to a client who has had surgery. Nalbuphine (Nubain) is prescribed for pain. For which side effects/adverse reactions should the nurse assess this client after administering this medication? Select all that apply.
1. Oliguria
2. Dry mouth
3. Palpitations
4. Constipation
5. Urinary retention
6. Orthostatic hypotension
2. Dry mouth
3. Palpitations
4. Constipation
5. Urinary retention
6. Orthostatic hypotension
Answer: 2, 3, 4, 6
Rationale: Dry mouth, palpitations, and constipation are side effects of nalbuphine HCl (Nubain). Also, orthostatic hypotension may occur with nalbuphine HCl. The ability to form urine is not affected; an increased urinary output or frequency may occur. Urinary urgency, not retention, is a reaction to nalbuphine HCl.
Rationale: Dry mouth, palpitations, and constipation are side effects of nalbuphine HCl (Nubain). Also, orthostatic hypotension may occur with nalbuphine HCl. The ability to form urine is not affected; an increased urinary output or frequency may occur. Urinary urgency, not retention, is a reaction to nalbuphine HCl.
NCLEX Exam Practice Question of the Week - 2/22/12
Question: A new mother expresses concern to a nurse regarding sudden infant death syndrome (SIDS). She asks the nurse how to position her new infant for sleep. The nurse appropriately tells the mother that the infant should be placed on the:
1. Side or prone
2. Back or prone
3. Stomach with the face turned
1. Side or prone
2. Back or prone
3. Stomach with the face turned
4. Back rather than on the stomach
Answer: 4
Rationale: Sudden infant death syndrome (SIDS) is the unexpected death of an apparently healthy infant younger than 1 year for whom an investigation of the death and a thorough autopsy fails to show an adequate cause of death. Several theories are proposed regarding the cause, but the exact cause is unknown. Nurses should encourage parents to place the infant on the back (supine) for sleep. Infants in the prone position (on the stomach) may be unable to move their heads to the side, increasing the risk of suffocation. The infant may have the ability to turn to a prone position from the side-lying position.
NCLEX Exam Practice Question of the Week - 2/29/12
Question: The nurse is administering eardrops to a 2-year-old child. Which statement indicates the correct method was used?
1. The ear is pulled down and back.
2. The ear is pulled upward and back.
3. The ear is pulled upward and outward.
4. The ear is not displaced during instillation.
1. The ear is pulled down and back.
2. The ear is pulled upward and back.
3. The ear is pulled upward and outward.
4. The ear is not displaced during instillation.
Answer: 1
Rationale: To straighten the ear canal in children, the ear, or auricle, should be pulled down and back. In adults, the ear should be pulled upward and outward (3). Answer options 2 and 4 are incorrect methods of ear medication instillation in any age group.
Rationale: To straighten the ear canal in children, the ear, or auricle, should be pulled down and back. In adults, the ear should be pulled upward and outward (3). Answer options 2 and 4 are incorrect methods of ear medication instillation in any age group.
NCLEX Exam Practice Question of the Week - 3/7/12
Question: An older adult client has an open wound over the coccyx that extends through the dermis and subcutaneous tissue, exposing the deep fascia. The wound edges are distinct, and the wound bed is a pink-red color. There is no bruising or sloughing. What stage of pressure ulcer is this wound?
1 Stage I
2 Stage II
3 Stage III
4 Stage IV
1 Stage I
2 Stage II
3 Stage III
4 Stage IV
Answer: 3
Rationale: This is classified as a stage III pressure ulcer because of the full-thickness tissue loss extending to the deep fascia. Subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. There may be undermining and tunneling. A stage I pressure ulcer is characterized by intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. A stage II pressure ulcer is characterized by partial-thickness loss of dermis presenting as a shallow, open ulcer with a red-pink wound bed without slough, which may also present as an intact or open/ruptured serum-filled blister. A stage IV pressure ulcer is characterized by full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed and often includes undermining and tunneling.
Rationale: This is classified as a stage III pressure ulcer because of the full-thickness tissue loss extending to the deep fascia. Subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. There may be undermining and tunneling. A stage I pressure ulcer is characterized by intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. A stage II pressure ulcer is characterized by partial-thickness loss of dermis presenting as a shallow, open ulcer with a red-pink wound bed without slough, which may also present as an intact or open/ruptured serum-filled blister. A stage IV pressure ulcer is characterized by full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed and often includes undermining and tunneling.
NCLEX Exam Practice Question of the Week - 3/14/12
Question: A nurse is reviewing the laboratory results for a client receiving tacrolimus (Prograf). Which laboratory result would indicate to the nurse that the client is experiencing an adverse effect of the medication?
1. Blood glucose of 200 mg/dL
2. Potassium level of 3.8 mEq/L
3. Platelet count of 300,000 cells/mm3
4. White blood cell count of 6000 cells/mm3
1. Blood glucose of 200 mg/dL
2. Potassium level of 3.8 mEq/L
3. Platelet count of 300,000 cells/mm3
4. White blood cell count of 6000 cells/mm3
Answer: 1
Rationale: A blood glucose level of 200 mg/dL is significantly elevated above the normal range of 70 to 110 mg/dL and suggests an adverse reaction. Other adverse reactions include neurotoxicity evidenced by headache, tremor, and insomnia; gastrointestinal effects such as diarrhea, nausea, and vomiting; hypertension; and hyperkalemia.
Rationale: A blood glucose level of 200 mg/dL is significantly elevated above the normal range of 70 to 110 mg/dL and suggests an adverse reaction. Other adverse reactions include neurotoxicity evidenced by headache, tremor, and insomnia; gastrointestinal effects such as diarrhea, nausea, and vomiting; hypertension; and hyperkalemia.
NCLEX Exam Practice Question of the Week - 3/21/12
Question: After a transurethral prostatectomy, a client returns to the postanesthesia care unit with a three-way indwelling catheter with continuous bladder irrigation. What nursing action is the priority?
1. Monitoring for signs of confusion
2. Observing the suprapubic dressing for drainage
3. Maintaining the client in the semi-Fowler position
4. Encouraging fluids by mouth as soon as the gag reflex returns
1. Monitoring for signs of confusion
2. Observing the suprapubic dressing for drainage
3. Maintaining the client in the semi-Fowler position
4. Encouraging fluids by mouth as soon as the gag reflex returns
Answer: 1
Rationale: Confusion is a response to cerebral edema. Cerebral edema is a complication of continuous bladder irrigation because of an excessive absorption of irrigating solution by the venous sinusoids during surgery. The surgery is performed through the urinary meatus and urethra; there is no suprapubic incision. It is unnecessary to keep the client in the semi-Fowler’s position. The client is initially NPO and then advanced to a regular diet as tolerated. Continuous irrigation supplies enough fluid to flush the bladder.
Rationale: Confusion is a response to cerebral edema. Cerebral edema is a complication of continuous bladder irrigation because of an excessive absorption of irrigating solution by the venous sinusoids during surgery. The surgery is performed through the urinary meatus and urethra; there is no suprapubic incision. It is unnecessary to keep the client in the semi-Fowler’s position. The client is initially NPO and then advanced to a regular diet as tolerated. Continuous irrigation supplies enough fluid to flush the bladder.
NCLEX Exam Practice Question of the Week - 3/28/12
Question: Nursing management of the child with acute glomerulonephritis (AGN) would include which interventions? Select all that apply.
1. Strict bedrest in the acute phase
2. Monitor for acute hypertension
3. Protein and sodium restricted diet
4. Daily weights with strict intake and output
5. Closely monitor serum albumin
6. Administer diuretics as ordered
Answers: 2, 4, 61. Strict bedrest in the acute phase
2. Monitor for acute hypertension
3. Protein and sodium restricted diet
4. Daily weights with strict intake and output
5. Closely monitor serum albumin
6. Administer diuretics as ordered
Rationale: Acute hypertension (2) should be anticipated and therefore monitored closely. Fluid overload is assessed by monitoring daily weights and intake and output (4). Diuretic therapy (6) is helpful in controlling the hypertension and edema in the early stages. Strict bedrest (1) is no longer required; most children fatigue easily and restrict their own activities. Sodium (3) is only moderately restricted but protein is not in the acute phase. The serum albumin (5) is closely monitored in nephrotic syndrome but not in AGN.
NCLEX Exam Practice Question of the Week - 4/4/12
Question: A client was started on oral anticoagulant therapy while hospitalized. The client is now being discharged to home and is intermittently confused. The nurse determines that the client has the best support system for successful anticoagulant therapy monitoring if the client:
1. Has a home health aide coming to the house for 9 weeks
2. Was going to stay with a daughter in the daughter’s home indefinitely
3. Was going to have blood work drawn in the home by a local laboratory
4. Has a good friend living next door who would take the client to the doctor
1. Has a home health aide coming to the house for 9 weeks
2. Was going to stay with a daughter in the daughter’s home indefinitely
3. Was going to have blood work drawn in the home by a local laboratory
4. Has a good friend living next door who would take the client to the doctor
Answer: 2
Rationale: The client taking anticoagulant therapy should be informed about the medication, its purpose, and the necessity of taking the proper dose at the specified times. If the client is unwilling or unable to comply with the medication regimen, the continuance of the regimen should be questioned. Clients may need support systems in place to enhance compliance
with therapy. Option 1 facilitates reminding the client to take the medication, option 3 facilitates blood work only, and option 4 facilitates medical care. Option 2 provides a direct support system.
Rationale: The client taking anticoagulant therapy should be informed about the medication, its purpose, and the necessity of taking the proper dose at the specified times. If the client is unwilling or unable to comply with the medication regimen, the continuance of the regimen should be questioned. Clients may need support systems in place to enhance compliance
with therapy. Option 1 facilitates reminding the client to take the medication, option 3 facilitates blood work only, and option 4 facilitates medical care. Option 2 provides a direct support system.
NCLEX Exam Practice Question of the Week - 4/11/12
Question: An adolescent is hospitalized with multiple internal injuries after an automobile collision. The adolescent is being kept npo and is receiving an IV infusion at 125 mL/hr and an antibiotic reconstituted in 10 mL of normal saline every 6 hours (1 am, 4 pm, 1 pm, 4 am). What is the intake from 7 am to 3 pm?
1. 1000 mL
2. 1010 mL
3. 1020 mL
4. 1030 mL
1. 1000 mL
2. 1010 mL
3. 1020 mL
4. 1030 mL
Answer: 2
Rationale: 1010 mL is the correct amount of intake. 125 mL X 8 hours = 1000 mL; one dose of the reconstituted antibiotic is administered at 1 p.m. = 10mL; 1000 mL + 10 mL = 1010 mL.
Rationale: 1010 mL is the correct amount of intake. 125 mL X 8 hours = 1000 mL; one dose of the reconstituted antibiotic is administered at 1 p.m. = 10mL; 1000 mL + 10 mL = 1010 mL.
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