NCLEX NCLEX-PN Online Practice Questions and Exam Preparation

NCLEX NCLEX-PN Online Questions & Answers

• Question 561:

  An Rh-negative woman with previous sensitization has delivered an Rh-positive fetus.

  Which of the following nursing actions should be included in the client's care plan?

  A. emotional support to help the family deal with feelings of guilt about the infant's condition
  B. administration of MICRhoGam to the woman within 72 hours of delivery
  C. administration of Rh-immune globulin to the newborn within 1 hour of delivery
  D. lab analysis of maternal Direct Coombs' test
  A. emotional support to help the family deal with feelings of guilt about the infant's condition

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  If a woman is sensitized to the Rh factor, it poses a threat to any Rh-positive fetus she delivers. The nurse needs to provide emotional support to help the family deal with the infant's condition, which might involve a host of conditions that could lead to death or marked neurological damage. RhoGam is never given to a woman already sensitized. If not previously sensitized, MICRhoGam (a smaller dose of Rh immune globulin) is given after an abortion or ectopic pregnancy to prevent sensitization. If not sensitized, RhoGam is given to the woman within 72 hours of delivery. Rh-immune globulin is never given to the newborn. To determine if sensitization has occurred, an Indirect Coombs' is drawn on the mother to measure the number of Rh-positive antibodies.

• Question 562:

  A primigravida begins labor when her family is unavailable and she is alone. She is very upset that her family is not with her. Which approach can the nurse take to meet the client's needs at this time?

  A. asking whether another individual wants to be her support person
  B. assuring her that the nursing triage group will be with her at all times
  C. telling her you will try to locate her family
  D. reinforcing the woman's confidence in her own abilities to cope and maintain a sense of control
  A. asking whether another individual wants to be her support person

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  Explanation Explanation/Reference:Allow the client to select another individual to give support. This allows her to have someone with her until her family can be with her.

• Question 563:

  The 24-hour day-night cycle is known as __________.

  A. circadian rhythm
  B. infradium rhythm
  C. ultradian rhythm
  D. non-REM rhythm
  A. circadian rhythm

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  Explanation Explanation/Reference:Circadian rhythm is rhythmic repetition of patterns each 24 hours. The other options are incorrect.

• Question 564:

  When suctioning a client, what is the usual amount of time the nurse should spend for each suction pass?

  A. 2 seconds
  B. 10 seconds
  C. 20 seconds
  D. 30 seconds
  B. 10 seconds

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  Explanation Explanation/Reference:Ten seconds is the usual amount of time the nurse should spend for each suction pass. Two seconds is not enough time to remove secretions. The remaining choices are too long and could lead to hypoxia and tissue trauma.

• Question 565:

  Which of the following needs immediate medical attention and emergency intervention?

  The client who __________.

  A. complains of sharp pain upon taking a deep breath and excessive coughing
  B. exhibits yellow, productive sputum, lowgrade fever, and crackles
  C. has a shift of the trachea to the left, with no breath sounds on the right
  D. has asthma and complains of an inability to catch her breath after exercise
  C. has a shift of the trachea to the left, with no breath sounds on the right

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  Choice "has a shift of the trachea to the left, with no breath sounds on the right" is indicative of a tension pneumothorax, which is considered a medical emergency. The respiratory system is severely compromised and venous return to the heart is affected. The mediastinal shift is to the unaffected side. Choice "complains of sharp pain upon taking a deep breath and excessive coughing" contains symptoms of pleurisy, and Choice "exhibits yellow, productive sputum, lowgrade fever, and crackles" lists symptoms of bronchitis. Neither are emergencies. The client in Choice "exhibits yellow, productive sputum, lowgrade fever, and crackles" should expect difficulty breathing after exercise when asthma is an existing condition and might need immediate attention if his rescue inhaler is ineffective.

• Question 566:

  A teenage client is admitted to the hospital because of acetaminophen (Tylenol) overdose.

  In which of the following organs overdoses of acetaminophen can precipitate life-threatening abnormalities?

  A. lungs
  B. liver
  C. kidneys
  D. adrenal glands
  B. liver

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  Explanation Explanation/Reference:Acetaminophen is extensively metabolized in the liver. Lungs, kidneys and adrenal glands are incorrect choices because prolonged use of acetaminophen might result in an increased risk of renal dysfunction, but a single overdose does not precipitate life-threatening problems in the respiratory system, renal system, or adrenal glands.

• Question 567:

  A patient has been ordered to get Tegretol for the first time. Which of the following side effects is not associated with Tegretol?

  A. Sore throat
  B. Vertigo
  C. Fever
  D. Shortness of breath
  D. Shortness of breath

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  Explanation Explanation/Reference:Sore throat, Vertigo, Fever are associated side effects of Tegretol.

• Question 568:

  The nurse can best communicate to a client that he or she has been listening by __________.

  A. restating the main feeling or thought the client has expressed
  B. making a judgment about the client's problem
  C. offering a leading question such as, "And then what happened?"
  D. saying, "I understand what you're saying."
  A. restating the main feeling or thought the client has expressed

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  Restating allows the client to validate the nurse's understanding of what has been communicated. It's an active listening technique. Regarding Choice "making a judgment about the client's problem", judgments should be suspended in a nurse-client relationship. Choice "offering a leading question such as, "And then what happened?" is incorrect because leading questions ask for more information rather than showing understanding. Choice "saying, "I understand what you're saying." communicates understanding, but the client has no way of measuring the understanding.

• Question 569:

  Which of the following values should the nurse monitor closely while a client is on total parenteral nutrition?

  A. calcium
  B. magnesium
  C. glucose
  D. cholesterol
  C. glucose

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  Glucose is monitored closely when a client is on total parenteral nutrition, due to high glucose concentration in the solutions. The other values are not monitored as closely.

• Question 570:

  When administering intravenous electrolyte solution, the nurse should take which of the following precautions?

  A. Infuse hypertonic solutions rapidly.
  B. Mix no more than 80 mEq of potassium per liter of fluid.
  C. Prevent infiltration of calcium, which causes tissue necrosis and sloughing.
  D. As appropriate, reevaluate the client's digitalis dosage. He might need an increased dosage because IV calcium diminishes digitalis's action.
  C. Prevent infiltration of calcium, which causes tissue necrosis and sloughing.

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  Preventing tissue infiltration is important to avoid tissue necrosis. To infuse hypertonic solutions rapidly is incorrect because hypertonic solutions should be infused cautiously and checked with the RN if there is a concern. To mix no more than 80 mEq of potassium per liter of fluid is incorrect because potassium, mixed in the pharmacy per physician order, is mixed at a concentration no higher than 60 mEq/L.