NCLEX-PN EAQs
Benztropine 2.5mg by mouth is prescribed. The medication is available in 1mg scored tablets. How many tablets would the nurse administer? Record the answer using one decimal place
2.5 (2.5 tables = 2 and 1 half of the 1mg tablets)
Which quantity of iron, ingested by a child, would be considered in the range of mildly to moderately toxic?
35mg/kg Rational: Ingestions of 20-60mg/kg of iron are considered mildly to moderately toxic. Ingestion of either 8mg/kg or 15mg/lg is too little to be considered toxic. Ingestions of amounts greater than 60mg/kg (here, 65 mg/kg) is severely toxic and may be fatal.
BECAUSE OF ITS ROLE IN WOUND HEALING, WHICH VITAMIN WOULD THE NURSE EXPECT THE HEALTH CARE PROVIDER TO PRESCRIBE FOR A CLIENT WITH LARGE SURGICAL INCISION?
ASCORBI ACID RATIONAL: VITAMIN C = ASCORBIC ACID AND PLAYS A MAJOR ROLE IN WOUND HEALING.
Which ophthalmic solution does the nurse recognize as a contraindication for the client diagnosed with glaucoma?
ATROPINE Rational: ATROPINE, a mydriatic ophthalmic solution, is contraindicated for client with glaucoma because it dilates the pupil. Increasing intraocular pressure. TIMOLOL, abeta blocker, decreases aqueous humor prodution; beta blockers are the preferred inital medication given to reduce intraocular pressure. PILOCARPINE a cholinergic, constricts the pupil, thereby increasing aqueous humor outflow. EPINEPHRINE, an adrenergic agent, enhances aqueous humor outflow, thereby reducing intraocular pressure
Which ophthalmic condition can be recognized by assessing the vision with a SNELLEN CHART, where the client is unable to read line 20 of the eye chart while standing at a distance of 20 feet?
Abnormal distant vision Rational: Abnormal distant vision can be confirmed in the client if the client is unable to read line 20 of the eye chart from a distance of 20 feet. A client can be suspected to have near-vision abnormality if unable to read a newspaper print from a distance of 14 inches. Loss of bilateral coordination of eye movement can be attributed to impaired eye movement. Any impairment of side vision up to 90 degrees from the central visual axis, upward vision of 50 degrees, and downward vision of 70 degrees can be suspected as impaired peripheral vision.
Which client ethnicity does the nurse recall has the highest rate of mortality associated with cervical cancer and should be included in preventative screening?
African American Rational: While Hispanic, Native American, and African American women all have a greater risk for cervical cancer when compared with white women, it is AFRICAN AMERICAN woman who has the highest rate of mortality, almost TWICE as high as the rate for white women. JAPANESE women have low risk for ovarian cancer; however, their risk is comparable to white women for second - and third- generation Japanese women in the United States.
WHICH TERM WOULD THE NURSE USE FOR SOFT, CRACKLING, BUBBLING BREATH SOUNDS MORE OBVIOUS ON INSPIRAITON?
CRACKLES Rational: CRACKLES ARE ABNORMAL BREATH SOUNDS DESCRIBED AS SOFT, CRACKLING BUBBLING SOUNDS PRODUCED BY AIR MOVING ACROSS FLUID IN THE ALVEOLI. VESICULAR BREATH SOUNDS ARE NORMAL. THEY ARE QUIET, SOFT AND INSPIRAITON SOUNDS THAT ARE SHORT AND ALMOST SILET ON EXPIRATION. THEY ARE HEARD OVER THE LUNG PERIPHERY. BRONCIAL BREATH SOUNDS ARE NORMAL AND CONSIST OF FULL INSPIRATION AND EXPIRATORY PHASE WITH THE EXPIRATORY PHASE BEING LOUDER. THEY ARE HEARD OVER THE TRACHEA AND LARGE BRONCHI OF THE LUNGS. RHONIC ARE ABNORMAL BREATH SOUNDS HEARD OVER THE LARGE AIRWAYS OF THE LUNGS. THEY CONSIST OF A LOW PITCH AND ARE CAUSE BY THE MOVEMENT OF SECREATIONS IN THE LARGER AIRAYS; THEY USALLY CLEAR WITH COUGHING.
The nurse would monitor for which initial sign of fluid overload, in a client receiving intravenous (IV) fluids to replace fluid loss from extensive burns?
CRACKLES IN THE LUNGS Rationals: Crackeles, or RALES in the lungs are an early sign of pulmonary congestion and edema cause by fluid overlaod. Clients with fluid overload will usually demonstrate an increased heart rate and increased blood pressure. A decreased heart rate, decreased blood pressure, and cyanosis in a client with fluid overload would be VERY LATE AND FATAL SIGNS.
WHICH STEP OF THE LPN NURSING PROCESS IS THE NURSE USING WHEN CONDUCTING A CLIENT'S PREOPERATIVE NURSING INTERVIEW
DATA COLLECTION RATIONAL: DURING THE PRE OPERAVTIVE CLIENT INTERVIEW, THE NURSE IS COLLECTING DATA.
Which instruction would the nurse give the client about isoniazid medication
Drinking alcohol daily can cause drug-induced hepatitis. Rational: Daily alcohol intake while taking isoniazid can cause drug-induced hepatitis. Prolonged use does not cause dark, concentrated urine. The client should take isoniazid with meals to decrease GI upset. Clietns
Which action is the staff nurse's ethical obligation when the nurse manager comes to work obviously intoxicated?
Have the supervisor validate the observtion Rationals: The staff nurse should call the supervisor to confirm and deal with the problem. The security guard has no authority in this situation. Although sending the nurse manager home removes the nurse manager from the clinical setting, it does not provide for documentation for the situation. Also, the nurse manager may be in no condition to go home independently. Drinking coffe does not make a person less intoxicated
WHICH STATEMENT ABOUT FILLING OUT AN INCIDENT REPORT INDICATES A NEED FOR FURTHER DISCUSSION?
INCLUDE THE NAME OF THE NURSE IN THE INCIDENT REPORT Rational: The nurse should include in the incident report the name of the health care provider notified and the care provided to the client. The nurse should avoid unnecessary details or admitting liability in the incident report but should include only objective and observed information. The nurse should avoid mentioning the incident report in the client's nursing note because doing so makes it easier for an attorney to request that document for a court case.
Which electrolyte in the intracellular fluid would the nurse consider most important?
Potassium Rational: The concentration of POTASSIUM is greater INSIDE the cell and is important in establishing a membrane potential, a critical factor in the cell's ability to function. SODIUM is the most abundant cation of the EXTRACELLULAR compartment, not the INTRACELLULAR compartment. CALCIUM is the most abundant electrolyte in the body; 99% is concentrated in the teeth and bones and only 1% is available for bodily functions. CHLORIDE is an extracellular, not intracellular anion.
IN THE UNITED STATES, WHICH STATEMENT DESCRIBES THE NURSE'S LEGAL RESPONSIBILITY REGARDING CHILD ABUSE?
REPORT ANY SUSPECTED ABUSE TO LOCAL LAW ENFORCEMENT AUTHORITIES RATIONAL: HEALTH CARE PROVIDERS ARE LEGALLY RESPONSIBLE FOR REPORTING SUSPECTED OR ACTUAL ABUSE. CHILD PROTECTIVE SERVICES MAY OBTAIN A COURT ORDER TO GRANT TEMPORARY GUARDIANSHIP IF IT IS FOUND THAT THE CHILD IS IN IMMEDIATE DANGER.
Which tag is suitable for a client which high priority during a disaster with mass casualties?
Red Rational: The red tag is assigned to a client who requires immediate emergent treatment since he or she has a life-treatening condition. A GREEN tag is assigned to a client who does not require immediate treatment. Black is assigned to a client who is about to die. YELLOW is assigned to a client with major injuries that requires immediate treatment
A CLIENT IN THE TERMINAL STAGE OF CANCER IS BEING ADMITTED TO THE HOSPICE CARE UNIT. ONCE MEMBER OF THE INTERDISCIPLINARY TEAM ASSISTS THE CLIENT AND FAMILY IN FILLING OUT INSURANCE PAPERS. WHICH TEAM MEMBER WOULD BE ASSISTING?
SOCIAL WORKER Rational: SOCIAL WORKER WOULD ASSIST IN FILLING OUT INSURANCE PAPERS AND SUPPORTING THE CLIENT AND CAREGIVIER WITH GRIEF ISSUES. A PRIMARY NURSE SERVES AS A LIASION AMONTH THE CLIENT AND CAREGIVER, HEALTH CARE PROVIDERS AND THE INTERDISCIPLINARY TEAM. A SPIRITUAL COORDINATOR SERVES AS A LIASION BETWEEN THE CLIENT AND THE SPIRITUAL COMMUNITY. A VOLUNTEER COORDIANTOR RECRUITS AND TRAINS VOLUNTEERS
Which condition does the nurse recognize when a client is unable to focus both eyes in the same direction?
Strabismus Rational: STRABISMUS is the inability of both the eyes to focus in the same direction. MYOPIA is the condition of nearsightedness. FARSIGHTEDNESS is otherwise referred to as HYPEROPIA. ASTIGMATISM is a defect in the curvature of the surface of the eye
WHICH ACTION WOULD THE NURSE TAKE INITIALLY WHEN FINDING CIGARETTES IN THE BATHROBE OF A CLIENT WHO WAS INSTRUCTED TO STOP SMOKING?
TELLING THE CLIENT THAT THE CIGARETTES WERE FOUND RATIONAL: HONER NURSE-CLIENT RELATIONSHIPS WOULD BE MAINTAINED SO THAT TRUST CAN DEVELOP
UNDER WHICH CIRCUMSTANCE WOULD THE NURSE EXPECT THE Z-TRACK TECHNIQUE TO BE NECESSARY/
THE MEDICATION IS IRRITATING TO SUBCUTANEOUS TISSUE AND SKIN Rational: THE Z-TRACK METHOS SEALS THE PUNCTURE AT THE INTRAMUSCULAR LEVEL, PREVENTING SEEPAGE OF INJECTED MEDICATION UP THE NEEDLE TRACK AND THEREBY AVOIDING INJURY TO SUBCUTANEOUS TISSUE AND SKIN.