Saunders NCLEX-PN Questions with Answers (100% Correct
Answers)
741. 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." —Answer: 741. 3
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.
Test-Taking Strategy: Note the strategic words, need for further teaching. These words indicate
a negative event query and the need to select the incorrect statement. Options 1 and 4 can be
easily eliminated because they are general interventions associated with convalescence.
Knowing that coughing spells are associated with pertussis will assist in directing you to the
correct option from the remaining options. In addition, a 2-week period of respiratory
precautions is not required. Review: home care instructions for the child with pertussis.
Level of Cognitive Ability: Evaluating
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Evaluation
Content Area: Child Health: Infectious and Communicable Diseases
Priority Concepts: Gas Exchange, Infection
© 2025 All rights reserved
, Reference(s): Hockenberry, Wilson (2013), pp. 428, 653-654.
742. A client enters the emergency department confused, twitching, and having seizures. His
family states he recently was placed on corticosteroids for arthritis and was feeling better and
exercising daily. Upon assessment, he has flushed skin, dry mucous membranes, an elevated
temperature, and poor skin turgor. His serum sodium level is 172 mEq/L. Which interventions
would the health care provider likely prescribe? Select all that apply.
1. Monitor the vital signs.
2. Monitor intake and output.
3. Increase water intake orally.
4. Monitor the electrolyte levels.
5. Provide a sodium-reduced diet.
6. Administer sodium replacements. —Answer: 742. 1, 2, 3, 4, 5
Rationale: Hypernatremia is described as having a serum sodium level that exceeds 145 mEq/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.
Test-Taking Strategy: Focus on the subject, a sodium level of 172 mEq/L. Knowledge that this
level is elevated and knowledge of the treatment for hyperkalemia will direct you to the correct
options. Review: hypernatremia.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Planning
Content Area: Fundamental Skills: Fluids & Electrolytes
© 2025 All rights reserved
Answers)
741. 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." —Answer: 741. 3
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.
Test-Taking Strategy: Note the strategic words, need for further teaching. These words indicate
a negative event query and the need to select the incorrect statement. Options 1 and 4 can be
easily eliminated because they are general interventions associated with convalescence.
Knowing that coughing spells are associated with pertussis will assist in directing you to the
correct option from the remaining options. In addition, a 2-week period of respiratory
precautions is not required. Review: home care instructions for the child with pertussis.
Level of Cognitive Ability: Evaluating
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Evaluation
Content Area: Child Health: Infectious and Communicable Diseases
Priority Concepts: Gas Exchange, Infection
© 2025 All rights reserved
, Reference(s): Hockenberry, Wilson (2013), pp. 428, 653-654.
742. A client enters the emergency department confused, twitching, and having seizures. His
family states he recently was placed on corticosteroids for arthritis and was feeling better and
exercising daily. Upon assessment, he has flushed skin, dry mucous membranes, an elevated
temperature, and poor skin turgor. His serum sodium level is 172 mEq/L. Which interventions
would the health care provider likely prescribe? Select all that apply.
1. Monitor the vital signs.
2. Monitor intake and output.
3. Increase water intake orally.
4. Monitor the electrolyte levels.
5. Provide a sodium-reduced diet.
6. Administer sodium replacements. —Answer: 742. 1, 2, 3, 4, 5
Rationale: Hypernatremia is described as having a serum sodium level that exceeds 145 mEq/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.
Test-Taking Strategy: Focus on the subject, a sodium level of 172 mEq/L. Knowledge that this
level is elevated and knowledge of the treatment for hyperkalemia will direct you to the correct
options. Review: hypernatremia.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Planning
Content Area: Fundamental Skills: Fluids & Electrolytes
© 2025 All rights reserved
