NCLEX NCLEX Certifications NCLEX-PN Questions & Answers

• Question 561:

  The nurse assesses a client for physiological risk factors for falls.

  The nurse should conclude that the client is not at risk if which of the following is discovered?

  A. history of dizziness

  B. need for wheelchair due to reduced mobility

  C. weakness and fatigue noted when climbing stairs

  D. intact recent and remote memory

  Correct Answer: D

  Intact recent and remote memory indicates that a client is not at risk for falls.

  Risk for falls can occur in elder clients, and the nurse should assess each client for the possibility of falls

  and take appropriate actions.

• Question 562:

  The nurse working with elderly clients should keep in mind that falls are most likely to happen to elderly who are __________.

  A. in their 80s

  B. living at home

  C. hospitalized

  D. living on only Social Security income

  Correct Answer: C

  Elder people are particularly prone to falling and incurring serious injury, especially in new situations and environments (such as the hospital).

• Question 563:

  A newborn has been delivered. An Apgar score is given. What does this scoring system indicate?

  A. heart rate, respiratory effort, color, muscle tone, reflex irritability

  B. heart rate, bleeding, cyanosis, edema

  C. bleeding, reflex, edema

  D. respiratory effort, heart rate, seizures

  Correct Answer: A

  The Apgar scoring system was put into place by Virginia Apgar, an anesthesiologist in New York, for the purpose of assessing newborns in the areas of heart rate, respiratory effort, color, muscle tone, and reflex irritability at 1, 5, and sometimes 10 minutes after birth.

• Question 564:

  Signs of internal bleeding include all of the following except __________.

  A. painful or swollen extremities

  B. a tender, rigid abdomen

  C. vomiting bile

  D. bruising

  Correct Answer: C

  Vomiting bile is usually not a sign of internal bleeding.

  Signs of internal bleeding include painful or swollen extremities; a tender, rigid abdomen; and bruising.

• Question 565:

  Which of the following microorganisms are considered normal body flora?

  A. staphylococcus on the skin

  B. streptococcus in the nares

  C. candida albicans in the vagina

  D. pseudomonas in the blood

  Correct Answer: A

  Of the choices given, only staphylococcus is considered a normal resident of the body.

• Question 566:

  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

  Correct Answer: A

  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 567:

  The nurse is teaching a client about communicable diseases and explains that a portal of entry is __________.

  A. a vector

  B. a source, like contaminated water

  C. food

  D. the respiratory system

  Correct Answer: D

  The path by which a microorganism enters the body is the portal of entry.

  A vector is a carrier of disease, a source (like bad water or food) can be a reservoir of disease.

• Question 568:

  Which of the following is responsible for laws mandating the reporting of certain infections and diseases?

  A. Centers for Disease Control and Prevention (CDC)

  B. individual state laws

  C. National Institute of Health Research (NIH)

  D. Health and Human Services (HHS)

  Correct Answer: B

  Individual state laws mandate the reporting of infectious diseases.

  The list of reportable diseases varies from state to state and is overseen by state health departments.

  CDC reporting is voluntary and done via collaboration with state agencies. There are 58 emerging

  infectious diseases under surveillance by the CDC.

• Question 569:

  Serum Vancomycin levels are taken to measure __________.

  A. renal function

  B. therapeutic range

  C. trough levels

  D. antibiotic resistance

  Correct Answer: B

  Vancomycin levels are monitored to ensure therapeutic effects by peak level. Trough level is that level of

  wash out or lowest level of drug just prior to the next dose. The blood is taken approximately 2 hours after

  an IV infusion.

  Renal function is measured by creatinine and BUN or creatinine clearance and resistance by sensitivity.

• Question 570:

  The client on Floxin must be alerted to which of the following adverse effects?

  A. stunting of height in teens and young adults

  B. propensity of anovulatory uterine bleeding

  C. intractable diarrhea

  D. tendon rupture

  Correct Answer: D

  Floxin is a quinolone antibiotic used in respiratory infections and pelvic and reproductive infections.

  Rarely, quinolones can cause tendon sheath rupture, usually of the Achilles.

  At the first indication of tendon pain, the antibiotic should be discontinued.