PN 3 NCLEX QUESTIONS AND ANSWERS WITH EXPLANATIONS Week 2 New update 2022/2023

PN 3 NCLEX QUESTIONS AND ANSWERS WITH
EXPLANATIONS Week 2 New update 2022/2023
The nurse reinforces home care instructions to the parents of a child
hospitalized with pertussis. The child is in the convalescent stage and is being
prepared for discharge. Which statement by the parents indicates a need for
further teaching?

1. “We need to encourage adequate fluid intake.”
2. “Coughing spells may be triggered by dust or smoke.”
3. “We need to maintain respiratory precautions and a quiet environment
for at least 2 weeks.”
4. “Good hand-washing techniques need to be instituted to prevent spreading
the disease to others.”


Rationale: Pertussis is transmitted by direct contact or respiratory droplets from
coughing. The communicable period occurs primarily during the catarrhal stage.
Respiratory precautions are not required during the convalescent phase. Options
1, 2, and 4 are components of home care instructions.


 A client enters the emergency department confused, twitching, and having
seizures. Upon assessment, flushed skin, dry mucous membranes, an
elevated temperature, and poor skin turgor is noted. The serum sodium
level is 172 mEq/L (172 mmol/L). Which interventions should the primary
health care provider (PHCP) likely prescribe? Select all that apply.


1. Monitor vital signs.
2. Monitor intake and output.


PN 3 NCLEX QUESTIONS AND ANSWERS WITH
EXPLANATIONS Week 2 New update 2022/2023

,PN 3 NCLEX QUESTIONS AND ANSWERS WITH
EXPLANATIONS Week 2 New update 2022/2023
3. Increase water intake orally.
4. Monitor electrolyte levels.
5. Provide a sodium-reduced diet.
6.Administer sodium replacements.

Rationale: Hypernatremia is described as having a serum sodium level that exceeds
145 mEq/L (145 mmol/L). Signs and symptoms would include dry mucous
membranes, loss of skin turgor, thirst, flushed skin, elevated temperature, oliguria,
muscle twitching, fatigue, confusion, and seizures. Interventions include monitoring
fluid balance, monitoring vital signs, reducing dietary intake of sodium, monitoring
electrolyte levels, and increasing oral intake of water. Sodium replacement therapy
would not be prescribed for a client with hypernatremia.




PN 3 NCLEX QUESTIONS AND ANSWERS WITH
EXPLANATIONS Week 2 New update 2022/2023

,PN 3 NCLEX QUESTIONS AND ANSWERS WITH
EXPLANATIONS Week 2 New update 2022/2023
3. The nurse is monitoring a client receiving glipizide. Which outcome
indicates an ineffective response from the medication?


1.A decrease in polyuria
2.A decrease in polyphagia
3.A glycosylated hemoglobin level of 12%
4.A fasting plasma glucose of 100 mg/dL (5.7 mmol/L)

Rationale: Glipizide is an oral hypoglycemic agent administered to decrease the
serum glucose level and the signs and symptoms of hyperglycemia. Therefore, a
decrease in both polyuria and polyphagia would indicate a therapeutic response.
Laboratory values are also used to monitor a client’s response to treatment. A
fasting blood glucose level of 100 mg/dL (5.7 mmol/L) is within normal limits.
However, glycosylated hemoglobin of 12% indicates poor glycemic control.


4. The nurse is reinforcing discharge instructions to a client receiving
sulfisoxazole. Which should be included in the plan of care for instructions?


1. Maintain a high fluid intake.
2. Discontinue the medication when feeling better.
3. If the urine turns dark brown, call the primary health care provider (PHCP)
immediately.
4. Decrease the dosage when symptoms are improving to prevent an allergic
response.

Rationale: Each dose of sulfisoxazole should be administered with a full glass of

PN 3 NCLEX QUESTIONS AND ANSWERS WITH
EXPLANATIONS Week 2 New update 2022/2023

, PN 3 NCLEX QUESTIONS AND ANSWERS WITH
EXPLANATIONS Week 2 New update 2022/2023
water, and the client should maintain a high fluid intake. The medication is more
soluble in alkaline urine. The client should not be instructed to taper or
discontinue the dose. Some forms of sulfisoxazole cause the urine to turn dark
brown or red. This does not indicate the need to notify the primary health care
provider.


5. Before administering an intermittent tube feeding through a nasogastric
tube, the nurse checks for gastric residual volume. Which is the best rationale
for checking gastric residual volume before administering the tube feeding?


1. Observe the digestion of formula.
2. Check fluid and electrolyte status.
3. Evaluate absorption of the last feeding.
4. Confirm proper nasogastric tube placement.

Rationale: All the stomach contents are aspirated and measured before
administering a tube feeding. This procedure measures the gastric residual
volume. The gastric residual volume is checked to confirm whether undigested
formula from a previous feeding remains and thereby evaluates the absorption of
the last feeding. It is important to check the gastric residual before administration
of a tube feeding. A full stomach could result in overdistention, thus predisposing
the client to regurgitation and possible aspiration. If residual feeding is obtained,
the PHCP’s prescription and agency policy are checked to determine the course of
action (hold or reduce the
volume of the intermittent tube feeding).
6. A postoperative client requests medication for flatulence (gas pains).
PN 3 NCLEX QUESTIONS AND ANSWERS WITH
EXPLANATIONS Week 2 New update 2022/2023