NCLEX-PN 3000 Questions and Correct Answers |
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The parent of a preschooler with chickenpox asks the nurse about
measures to make the child comfortable. The nurse instructs the parent
to avoid administering aspirin or any other product that contains
salicylates. When given to children with chickenpox, aspirin has been
linked to which disorder?
1. Guillain-Barré syndrome
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2. Rheumatic fever
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3. Reye's syndrome
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4. Scarlet fever
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Ans: Correct Answer: 3
RATIONALES: Research shows a correlation between the use of aspirin
during chickenpox and the development of Reye's syndrome (a disorder
characterized by brain and liver toxicity). Therefore, the nurse should
instruct the parents to avoid administering aspirin or other products that
contain salicylates and to consult the physician or pharmacist before
administering any medication to a child with chickenpox. No research
has found a link between aspirin use, chickenpox, and the development
of Guillain-Barré syndrome, rheumatic fever, or scarlet fever.
A client is to have an epidural block to relieve labor pain. The nurse
anticipates that the anesthesiologist will inject the anesthetic agent into
the:
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1. subarachnoid space.
2. area between the subarachnoid space and the dura mater.
3. area between the dura mater and the ligamentum flavum.
4. ligamentum flavum.
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Ans: Correct Answer: 3
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RATIONALES: For an epidural block, the nurse should anticipate that the
anesthesiologist will inject a local anesthetic agent into the epidural
space, located between the dura mater and the ligamentum flavum in the
lumbar region of the spinal column. When administering a spinal block,
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the anesthesiologist injects the anesthetic agent into the subarachnoid
space. The ligamentum flavum and the area between the subarachnoid
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space and the dura mater are inappropriate injection sites.
The physician prescribes penicillin potassium oral suspension 56
mg/kg/day in four divided doses for a client with anorexia nervosa who
weighs 25 kg. The medication dispensed by the pharmacy contains a
dosage strength of 125 mg/5 ml. How many milliliters of solution should
the nurse administer with each dose?
Ans: Correct Answer: 14
RATIONALES: To determine the total daily dosage, set up the following
proportion:
25 kg/X = 1 kg/56 mg
X = 1,400 mg.
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Next, divide the daily dosage by four doses to determine the dose to
administer every 6 hours:
X = 1,400 mg/4 doses
X = 350 mg/dose.
The adolescent should receive 350 mg every 6 hours.
Lastly, calculate the volume to give for each dose by setting up this
proportion:
X/350 mg = 5 ml/125 mg
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X = 14 ml.
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The nurse must irrigate a gaping abdominal incision with sterile normal
saline, using a piston syringe. How should the nurse proceed?
1. Irrigate continuously until the solution becomes clear or all of the
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solution has been used.
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2. Moisten the area around the wound with normal saline after the
irrigation.
3. Apply a wet-to-dry dressing to the wound after the irrigation.
4. Rapidly instill a stream of irrigating solution into the wound.
Ans: Correct Answer: 1
RATIONALES: To wash away tissue debris and drainage effectively, the
nurse should irrigate the wound until the solution becomes clear or all of
the solution has been used. After the irrigation, the nurse should dry the
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area around the wound; moistening it promotes microorganism growth
and skin irritation. When the area is dry, the nurse should apply a sterile
dressing, rather than awet-to-dry dressing. The nurse always should
instill the irrigating solution gently; rapid or forceful instillation can
damage tissues.
As an adolescent is receiving care, he's inadvertently injured with a warm
compress. The nurse completes an incident report based on the
knowledge that identification of which of the following is a goal of the
report?
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1. To reprimand the involved staff members for their actions
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2. To identify the learning needs of staff to prevent incident recurrences
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3. To reprimand the nurse-manager responsible for the unit
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4. To hold people accountable for their actions
Ans: Correct Answer: 2
RATIONALES: The purpose of an incident report is threefold: to identify
ways to prevent incident recurrences, to identify patterns of care
problems, and to identify facts surrounding each incident. Incident
reports aren't used to hold people accountable for their actions, to
punish those involved in the incident, or to punish the nurse-manager
responsible for the unit.
As a client progresses through pregnancy, she develops constipation.
What is the primary cause of this problem during pregnancy?
1. Decreased appetite