NCLEX NCLEX Certifications NCLEX-PN Questions & Answers

• Question 121:

  A client admitted to the medical nursing unit has classic symptoms of tuberculosis (TB) and tests positive on the purified protein derivative (PPD) skin test. Several months later, the nurse who cared for the client also tests positive on an annual TB skin test for work.

  The most likely course of treatment if the chest X-ray (CXR) is negative is to __________.

  A. repeat a TB skin test in six months

  B. treat the nurse with an anti-infective agent for six months

  C. monitor for signs and symptoms within the next year

  D. follow up in one year at the next annual physical with CXR only

  Correct Answer: B

  Exposure with a positive TB skin test usually requires six months of prophylactic treatment unless contraindicated. The TB skin test should not be repeated; the results will always be positive. A CXR is

  usually not required annually in the event that the skin test was positive.

  TB is a type of pneumonia caused by the acid-fast bacillus, mycobacterium tuberculosis, and is contracted

  by airborne droplets that enter the lungs and multiply in the pulmonary alveoli.

  Nursing Assessment:

  (1)

  Assessment includes symptom analysis of type and progression of symptoms; color, consistency, and

  amount of sputum; knowledge of the disease; weight pattern; vital signs; description of any pain; palpable

  lymph nodes; breath sounds; and activity tolerance.

  (2)

  Diagnostic tests:

  ?CXR (shows dense lesions in the upper lobes, enlarged lymph nodes, and formation of large cavities);

  ?CBC (presence of leukocytosis);

  ?Fiberoptic bronchoscopy and bronchial washing (for obtaining culture specimens);

  ?Tuberculin skin test (positive at 5 to 9 mm for clients with abnormal CXR or HIV; positive at 10 to 15 mm

  for clients with high-risk factors such as intravenous [IV] drug use; residence in a long-term facility, high-

  incidence country; positive at 15 mm for all other people);

  ?Three early-morning sputum collections for acid-fast staining, culture and sensitivity positive for M.

  tuberculosis. Results can take up to 10 days.

• Question 122:

  A nurse is teaching a client newly diagnosed with Emphysema about the disease process.

  Which of the following statements best explains the problems associated with emphysema and could be adapted for use in the nurse's discussion with the client?

  A. Hyperactivity of the medium-sized bronchi caused by an inflammatory response leads to wheezing and tightness in the chest.

  B. Larger than normal air spaces and loss of elastic recoil cause air to be trapped in the lung and collapse airways.

  C. Vasodilation, congestion, and mucosal edema cause a chronic cough and sputum production.

  D. Chloride is not being transported properly, producing excess absorption of water and sodium, and thick viscous mucus.

  Correct Answer: B

  Larger-than-normal air spaces and loss of elastic recoil cause air to be trapped in the lung and collapse

  airways.

  Emphysema is a breakdown of the elastin and fiber network of the alveoli where the alveoli enlarge or the

  walls are destroyed. This alveolar destruction leads to the formation of larger-than-normal air spaces.

  Emphysema is one of a group of pulmonary diseases of a chronic nature characterized by increased

  resistance to airflow; the entity is part of chronic obstructive pulmonary disease (COPD).

• Question 123:

  A client was involved in a motor vehicle accident in which the seat belt was not worn. The client is exhibiting crepitus, decreased breath sounds on the left, complains of shortness of breath, and has a respiratory rate of 34/min.

  Which of the following assessment findings should concern the nurse the most?

  A. temperature of 102?F and a productive cough

  B. arterial blood gases (ABGs) with a PaO2 of 92 and PaCO2 of 40 mmHg

  C. trachea deviating to the right D. barrel-chested appearance

  Correct Answer: C

  A mediastinal shift is indicative of a tension pneumothorax along with the other symptoms in the question.

  Because the individual was involved in an MVA, assessment is targeted at acute traumatic injuries to the

  lungs, heart, or chest wall rather than other conditions indicated in the other choices.

  Temperature of 102?F and a productive cough is common with pneumonia.

  Arterial blood gases (ABGs) with a PaO2 of 92 and PaCO2 of 40 mmHg is not alarming.

  Barrel-chested appearance is typical of someone with chronic obstructive pulmonary disease (COPD).

  A tension pneumothorax is a dangerous complication and a medical emergency where entering air cannot

  escape by the same route and pressure within the pleural cavity increases, resulting in complete collapse

  of the lung.

  A mediastinal shift to the unaffected side and a downward displacement of the diaphragm can be

  observed.

• Question 124:

  A person using over-the-counter nasal decongestant drops who reports unrelieved and worsening nasal congestion should be instructed to __________.

  A. switch to a stronger dose of the medication

  B. discontinue the medication for a few weeks

  C. continue taking the same medication, but use it more frequently

  D. use a combination of medications for better relief

  Correct Answer: B

  Prolonged use of decongestant drops (3 to 5 days) can lead to rebound congestion, which is relieved by discontinuing the medication for 2 to 3 weeks. Nasal congestion results from dilation of nasal blood vessels due to infection, inflammation, or allergy. With this dilation, there is a transudation of fluid into the tissue spaces, resulting in swelling of the nasal cavity. Nasal decongestants (sympathomimetic amines) stimulate the alphaadrenergic receptors, producing vascular constriction (vasoconstriction) of the capillaries within the nasal mucosa. The result is shrinking of the nasal mucous membranes and a reduction in fluid secretion (runny nose). Decongestants can make a client jittery, nervous, or restless. These side effects decrease or disappear as the body adjusts to the drug. When nasal decongestants are used for longer than 5 days, instead of the nasal membranes constricting, vasodilation occurs, causing increased stuffy nose and nasal congestion. The nurse should emphasize the importance of limiting the use of nasal sprays and drops. As with any alpha-adrenergic drug (for example, decongestants), blood pressure and blood glucose levels can increase. These drugs are contraindicated and should only be used with extreme caution for clients with hypertension, cardiac disease, hyperthyroidism, and diabetes mellitus.

• Question 125:

  A client has been admitted in septic shock. Her nursing care plan includes the diagnosis High Risk for Injury (related to clotting disorder).

  Based on this diagnosis, all the following are appropriate entries in the nursing care plan except __________.

  A. obtain an order for a stool softener

  B. administer packed RBCs, if ordered

  C. encourage the client to rinse her mouth with mouthwash and scrub her teeth with an oral sponge

  D. dress venipuncture sites immediately to prevent infection

  Correct Answer: D

  Firm, direct pressure should be applied to venipuncture sites for 3-7 minutes before final dressing because of the clotting abnormality. Septic shock is a systemic infection of the bloodstream producing clinical manifestations ?warm, flushed skin; high urine output; tachycardia; edema; respiratory problems; restlessness; altered level of consciousness; life-threatening form of shock.

• Question 126:

  A 21-year-old college student has just learned that she contracted genital herpes from her sexual partner. After completing the initial history and assessment, the nurse has data concerning areas pertinent to the disease.

  The data is likely to include all but which of the following?

  A. voiding patterns

  B. characteristics of lesions

  C. vaginal discharge

  D. prior history of varicella

  Correct Answer: D

  The other choices are common reasons for which clients with herpes seek care.

• Question 127:

  Ten-year-old Jackie is admitted to the hospital with a medical diagnosis of Rheumatic Fever. She relates a history of "a sore throat about a month ago." Bed rest with bathroom privileges is prescribed.

  Which of the following nursing assessments should be given the highest priority when assessing Jackie's condition?

  A. her response to being hospitalized

  B. the presence of a macular rash on her trunk

  C. her cardiac status

  D. the presence of polyarthritis and pain in her joints

  Correct Answer: C

  Monitoring cardiac status is of the highest priority. Permanent cardiac damage can result from rheumatic

  fever.

  The second priority is assessing the client's joints for the presence of polyarthritis and accompanying pain.

• Question 128:

  The best nursing diagnosis for a client with newly diagnosed Diabetes Mellitus is __________.

  A. Impaired Skin Integrity

  B. Knowledge Deficit: New Diabetes Diagnosis

  C. Alteration in Nutrition: More than Body Requirements

  D. Fluid Volume Deficit

  Correct Answer: B

  Newly diagnosed diabetics need to learn about their disease, medications, glucose testing, possibly insulin injections, foot care, sick-day plans, and so forth. Impaired Skin Integrity and Fluid Volume Deficit are diagnoses to prevent, but no evidence suggests that they exist at this point. Diabetics might have more or less nutrition than body requirements ?type II is likely to be more, but type I is likely to be less.

• Question 129:

  If a client is suffering from thyroid storm, the PN can expect to find on assessment __________.

  A. tachycardia and hyperthermia

  B. bradycardia and hypothermia

  C. a large goiter

  D. a calm, quiet client

  Correct Answer: A

  In thyroid storm, there is too much thyroxine, causing the client to go faster. Atrial fibrillation and

  palpitations are also frequently seen.

  Bradycardia and hypothermia, a large goiter and a calm, quiet client are associated with hypothyroidism.

• Question 130:

  The PN is caring for a client with diabetes insipidus.

  The nurse can expect the lab work to show __________.

  A. elevated urine osmolarity and elevated serum osmolarity

  B. decreased urine osmolarity and decreased serum osmolarity

  C. elevated urine osmolarity and decreased serum osmolarity

  D. decreased urine osmolarity and elevated serum osmolarity

  Correct Answer: D

  In diabetes insipidus, the pituitary releases too much antidiuretic hormone (ADH) causing the client to produce a large amount of dilute (decreased osmolarity) urine and causing dehydration (elevated serum osmolarity). Elevated urine osmolarity and decreased serum osmolarity might be seen in a client with SIADH (syndrome of inappropriate ADH). Elevated urine osmolarity and elevated serum osmolarity, decreased urine osmolarity and decreased serum osmolarity generally don't occur ?urine and serum osmolarity typically move in opposite directions.