NCLEX NCLEX-PN Online Practice Questions and Exam Preparation

NCLEX NCLEX-PN Online Questions & Answers

• Question 811:

  A client with Kawasaki disease has bilateral congestion of the conjunctivae, dry cracked lips, a strawberry tongue, and edema of the hands and feet followed by desquamation of fingers and toes.

  Which of the following nursing measures is most appropriate to meet the expected outcome of positive body image?

  A. administering immune globulin intravenously
  B. assessing the extremities for edema, redness and desquamation every 8 hours
  C. explaining progression of the disease to the client and his or her family
  D. assessing heart sounds and rhythm
  C. explaining progression of the disease to the client and his or her family

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  Teaching the client and family about progression of the disease includes explaining when symptoms can be expected to improve and resolve. Knowledge of the course of the disease can help them understand that no permanent disruption in physical appearance will occur that could negatively affect body image. Clients with Kawasaki disease might receive immune globulin intravenously to reduce the incidence of coronary artery lesions and aneurysms. Cardiac effects could be linked to body image, but Choice 3 is the most direct link to body image. The nurse assesses symptoms to assist in evaluation of treatment and progression of the disease.

• Question 812:

  You have been assigned to care for a neonate who has been diagnosed with the Tetralogy of Fallot. The mother asks you what the Tetralogy of Fallot is.

  How should you respond to this mother?

  A. "The Tetralogy of Fallot is a congenital gastrointestinal disorder"
  B. "The Tetralogy of Fallot is a congenital cardiac disorder"
  C. "The Tetralogy of Fallot will affect the baby's reflexes"
  D. "The Tetralogy of Fallot will affect the baby's ability to breastfeed"
  B. "The Tetralogy of Fallot is a congenital cardiac disorder"

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  The Tetralogy of Fallot is a congenital cardiac disorder that is classified as a cyanotic, rather than acyanotic, congenital heart disorder that is characterized with abnormal cardiac anomalies. There is no relationship between the Tetralogy of Fallot and reflexes or breastfeeding.

• Question 813:

  The LPN reviews a patient's ABG results:

  pH 7.41, PO2 86 mmHg, PCO2 39 mmHg, HCO3 32 mEq/L.

  Which of the results is out of range?

  A. PO2
  B. HCO3
  C. PCO2
  D. pH
  B. HCO3

• Question 814:

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

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  Explanation Explanation/Reference: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 815:

  The only time that an individual may receive medical care without giving informed consent is __________.

  A. when the durable power of attorney for health care is not available
  B. in an emergency, life-or-death situation
  C. when the physician is not available for discussion with the client
  D. when they (clients) are not able to speak for themselves
  B. in an emergency, life-or-death situation

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  Treatment may be given without consent in a life-threatening situation. Choices "when the durable power of attorney for health care is not available", "when the physician is not available for discussion with the client", "when they (clients) are not able to speak for themselves" are incorrect. All attempts to notify a durable power of attorney for health care should be made. If unavailable, the physician assumes responsibility for treatment within facility protocol. The physician is obligated to have a discussion with the client in all nonlife-threatening situations. If clients are not able to speak for themselves, their power of attorney for health care or responsible party is involved in the consent process.

• Question 816:

  A 32-year-old female frequently comes to her primary care provider with vague complaints of headache, abdominal pain, and trouble sleeping. In the past, the physician has dutifully prescribed medication, but little else. Which of the following comments by the nurse to the physician is appropriate?

  A. "Often women who are victims of domestic violence suffer vague symptoms such as abdominal pain."
  B. "Often women become offended if asked about their safety in relationships."
  C. "It is mandatory that all women be questioned about domestic violence."
  D. "How would you feel to know that her partner is beating her and you didn't ask?"
  A. "Often women who are victims of domestic violence suffer vague symptoms such as abdominal pain."

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  Explanation Explanation/Reference:There is a correlation between vague symptoms, such as abdominal pain, and battered syndrome. The astute clinician should question any woman who presents with suspicious symptoms such as these. Rarely are women offended by a properly worded question, such as, "Do you feel safe in your present relationship?" Studies show an increase in case finding when such questions are asked. It is not mandatory that all women are assessed for violence, but it is prudent that all persons new to a clinician be assessed by at least the one question noted previously. Castigating or shaming the physician typically does not improve client outcomes and might make for a difficult working environment for the nurse. Tactless comments, like the Choice "How would you feel to know that her partner is beating her and you didn't ask?", are not collegial and should be avoided.

• Question 817:

  The nurse has completed client teaching about introducing solid foods to an infant. To evaluate teaching, the nurse asks the mother to identify an appropriate first solid food. Which of the following is an appropriate response?

  A. pureed canned squash
  B. pureed apples
  C. yogurt
  D. infant rice cereal
  D. infant rice cereal

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  Explanation Explanation/Reference:Single-grain infant cereals are recommended first because they are easily digestible and have added iron content. Yogurt is incorrect because yogurt is a milk product and introduction should be delayed until the child is 12 months of age because of the risk of milk allergy. Pureed canned squash and pureed apples are incorrect because fruits and vegetables are usually given following the introduction of cereals.

• Question 818:

  To ensure proper immobilization and increase client comfort when using a rigid splint ___________.

  A. place the client on a stretcher before splinting
  B. place the client on a long spine board before splinting
  C. pad the spaces between the body part and the splint
  D. ensure that the splint conforms to the body curves
  C. pad the spaces between the body part and the splint

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  Explanation Explanation/Reference:To ensure proper immobilization and increase client comfort when using a rigid splint, pad the spaces between the body part and the splint.

• Question 819:

  Which electrolyte is essential for enzyme and neurochemical activities?

  A. Chloride
  B. Magnesium
  C. Potassium
  D. Phosphate
  B. Magnesium

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  Magnesium is essential for enzyme and neurochemical activities and it is also needed for cardiac and skeletal muscle excitability. Chloride is the most abundant negatively charged ion in extracellular fluid with potassium being the most abundant positively charge ion. Phosphate assists in acid-base regulation.

• Question 820:

  Which of these is not a potential side effect of peritoneal dialysis?

  A. weight loss
  B. hyperglycemia
  C. hernia
  D. infection
  A. weight loss