NCLEX PN 2020/2021-QUESTIONS FROM PREVIOUS ACTUAL EXAMS

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NCLEX PN 2020/2021-QUESTIONS FROM PREVIOUS ACTUAL EXAMS The nurse is caring for a client scheduled for removal of the pitu- itary gland. The nurse should be particularly alert for: ❍ A. Nasal con... gestion ❍ B. Abdominal tenderness ❍ C. Muscle tetany ❍ D. Oliguria Correct Answer: Answer A is correct. Removal of the pituitary gland is usually done by a transphe- noidal approach, through the nose. Nasal congestion further interferes with the airway. Answers B, C, and D are not correct because they are not directly associated with the pituitary gland. A client with cancer is admitted to the oncology unit. Stat lab val- ues reveal Hgb 12.6, WBC 6500, K+ 1.9, uric acid 7.0, Na+ 136, and platelets 178,000. The nurse evaluates that the client is expe- riencing which of the following? ❍ A. Hypernatremia ❍ B. Hypokalemia ❍ C. Myelosuppression ❍ D. Leukocytosis Correct Answer: Answer B is correct.Hypokalemia is evident from the lab values listed.The other lab- oratory findings are within normal limits, making answers A, C, and D incorrect. 3. A 24-year-old female client is scheduled for surgery in the morn- ing. Which of the following is the primary responsibility of the nurse? ❍ A.Taking the vital signs ❍ B.Obtaining the permit ❍ C.Explaining the procedure ❍D. Checking the lab work Correct Answer: Answer A is correct. The primary responsibility of the nurse is to take the vital signs before any surgery. The actions in answers B, C, and D are the responsibility of the doctor and, therefore, are incorrect for this question. The nurse is working in the emergency room when a client arrives with severe burns of the left arm, hands, face, and neck. Which action should receive priority? ❍ A.Starting an IV ❍ B.Applying oxygen ❍ C.Obtaining blood gases ❍ D.Medicating the client for pain Correct Answer: Answer B is correct. The client with burns to the neck needs airway assessment and supplemental oxygen, so applying oxygen is the priority. The next action should be to start an IV and medicate for pain, making answers A and C incorrect. Answer D, obtaining blood gases, is ordered by the doctor. The nurse is visiting a home health client with osteoporosis. The client has a new prescription for alendronate (Fosamax). Which instruction should be given to the client? ❍ A.Rest in bed after taking the medication for at least 30 minutes ❍ B.Avoid rapid movements after taking the medication ❍ C.Take the medication with water only ❍ D.Allow at least 1 hour between taking the medicine and taking other medications Correct Answer: AnswerCiscorrect.Fosamaxshouldbetakenwithwateronly.Theclientshouldalso remain upright for at least 30 minutes after taking the medication. Answers A, B, and D are not applicable to taking Fosamax and, thus, are incorrect. The nurse is making initial rounds on a client with a C5 fracture and crutchfield tongs. Which equipment should be kept at the bedside? ❍ A.A pair of forceps ❍ B.A torque wrench ❍ C.A pair of wire cutters ❍ D.A screwdriver Correct Answer: AnswerBiscorrect.Atorquewrenchiskeptatthebedsidetotightenandloosenthe screws of crutchfield tongs. This wrench controls the amount of pressure that is placed on the screws. A pair of forceps, wire cutters, and a screwdriver, in answers A, C, and D, would not be used and, thus, are incorrect. An infant weighs 7 pounds at birth. The expected weight by 1 year should be: ❍ A. 10pounds ❍ B. 12pounds ❍ C. 18pounds ❍ D. 21pounds Correct Answer: AnswerDiscorrect.Abirthweightof7poundswouldindicate21poundsin1year, or triple his birth weight. Answers A, B, and C therefore are incorrect. A client is admitted with a Ewing's sarcoma. Which symptoms would be expected due to this tumor's location? ❍ A. Hemiplegia ❍ B. Aphasia ❍ C. Nausea ❍ D. Bonepain Correct Answer: AnswerDiscorrect.Sarcomaisatypeofbonecancer;therefore,bonepainwouldbe expected. Answers A, B, and C are not specific to this type of cancer and are incorrect. The nurse is caring for a client with epilepsy who is being treated with carbamazepine (Tegretol). Which laboratory value might indi- cate a serious side effect of this drug? ❍ A. Uric acid of 5mg/dL ❍ B.Hematocrit of 33% ❍ C.WBC 2,000 per cubic millimeter ❍ D.Platelets 150,000 per cubic millimeter Correct Answer: AnswerCiscorrect.Tegretolcansuppressthebonemarrowanddecreasethewhite blood cell count; thus, a lab value of WBC 2,000 per cubic millimeter indicates side effects of the drug. Answers A and D are within normal limits, and answer B is a lower limit of normal; therefore answers A, B, and D are incorrect. A 6-month-old client is admitted with possible intussuception. Which question during the nursing history is least helpful in obtaining information regarding this diagnosis? ❍ A."Tell me about his pain." ❍ B."What does his vomit look like?" ❍ C."Describe his usual diet." ❍ D."Have you noticed changes in his abdominal size?" Correct Answer: AnswerCiscorrect.Theleast-helpfulquestionsarethosedescribinghisusualdiet.A, B, and D are useful in determining the extent of disease process and, thus, are incor- rect. The nurse is assisting a client with diverticulosis to select appro- priate foods. Which food should be avoided? ❍ A.Bran ❍ B.Fresh peaches ❍ C.Cucumber salad ❍ D.Yeast rolls Correct Answer: AnswerCiscorrect.Theclientwithdiverticulitisshouldavoidfoodswithseeds.The foods in answers A, B, and D are allowed; in fact, bran cereal and fruit will help pre- vent constipation. A client has rectal cancer and is scheduled for an abdominal per- ineal resection. What should be the priority nursing care during the post-op period? ❍ A.Teaching how to irrigate the illeostomy ❍ B.Stopping electrolyte loss in the incisional area ❍ C.Encouraging a high-fiber diet ❍ D.Facilitating perineal wound drainage Correct Answer: AnswerDiscorrect.Theclientwithaperinealresectionwillhaveaperinealincision. Drains will be used to facilitate wound drainage. This will help prevent infection of the surgical site. The client will not have an illeostomy, as in answer A; he will have some electrolyte loss, but treatment is not focused on preventing the loss, so answer B is incorrect. A high-fiber diet, in answer C, is not ordered at this time. The nurse is performing discharge teaching on a client with diver- ticulitis who has been placed on a low-roughage diet. Which food would have to be eliminated from this client's diet? ❍ A.Roasted chicken ❍ B.Noodles ❍ C.Cooked broccoli ❍ D.Custard Correct Answer: AnswerCiscorrect.Theclientwithdiverticulitisshouldavoideatingfoodsthatare gas forming and that increase abdominal discomfort, such as cooked broccoli. Foods such as those listed in answers A, B, and D are allowed. NCLEX PN 2020/2021-QUESTIONS FROM PREVIOUS ACTUAL EXAMS The nurse is caring for a client scheduled for removal of the pitu- itary gland. The nurse should be particularly alert for: ❍ A. Nasal congestion ❍ B. Abdominal tenderness ❍ C. Muscle tetany ❍ D. Oliguria Correct Answer: Answer A is correct. Removal of the pituitary gland is usually done by a transphe- noidal approach, through the nose. Nasal congestion further interferes with the airway. Answers B, C, and D are not correct because they are not directly associated with the pituitary gland. A client with cancer is admitted to the oncology unit. Stat lab val- ues reveal Hgb 12.6, WBC 6500, K+ 1.9, uric acid 7.0, Na+ 136, and platelets 178,000. The nurse evaluates that the client is expe- riencing which of the following? ❍ A. Hypernatremia ❍ B. Hypokalemia ❍ C. Myelosuppression ❍ D. Leukocytosis Correct Answer: Answer B is correct.Hypokalemia is evident from the lab values listed.The other lab- oratory findings are within normal limits, making answers A, C, and D incorrect. 3. A 24-year-old female client is scheduled for surgery in the morn- ing. Which of the following is the primary responsibility of the nurse? ❍ A.Taking the vital signs ❍ B.Obtaining the permit ❍ C.Explaining the procedure ❍D. Checking the lab work Correct Answer: Answer A is correct. The primary responsibility of the nurse is to take the vital signs before any surgery. The actions in answers B, C, and D are the responsibility of the doctor and, therefore, are incorrect for this question. The nurse is working in the emergency room when a client arrives with severe burns of the left arm, hands, face, and neck. Which action should receive priority? ❍ A.Starting an IV ❍ B.Applying oxygen ❍ C.Obtaining blood gases ❍ D.Medicating the client for pain Correct Answer: Answer B is correct. The client with burns to the neck needs airway assessment and supplemental oxygen, so applying oxygen is the priority. The next action should be to start an IV and medicate for pain, making answers A and C incorrect. Answer D, obtaining blood gases, is ordered by the doctor. The nurse is visiting a home health client with osteoporosis. The client has a new prescription for alendronate (Fosamax). Which instruction should be given to the client? ❍ A.Rest in bed after taking the medication for at least 30 minutes ❍ B.Avoid rapid movements after taking the medication ❍ C.Take the medication with water only ❍ D.Allow at least 1 hour between taking the medicine and taking other medications Correct Answer: AnswerCiscorrect.Fosamaxshouldbetakenwithwateronly.Theclientshouldalso remain upright for at least 30 minutes after taking the medication. Answers A, B, and D are not applicable to taking Fosamax and, thus, are incorrect. The nurse is making initial rounds on a client with a C5 fracture and crutchfield tongs. Which equipment should be kept at the bedside? ❍ A.A pair of forceps ❍ B.A torque wrench ❍ C.A pair of wire cutters ❍ D.A screwdriver Correct Answer: AnswerBiscorrect.Atorquewrenchiskeptatthebedsidetotightenandloosenthe screws of crutchfield tongs. This wrench controls the amount of pressure that is placed on the screws. A pair of forceps, wire cutters, and a screwdriver, in answers A, C, and D, would not be used and, thus, are incorrect. An infant weighs 7 pounds at birth. The expected weight by 1 year should be: ❍ A. 10pounds ❍ B. 12pounds ❍ C. 18pounds ❍ D. 21pounds Correct Answer: AnswerDiscorrect.Abirthweightof7poundswouldindicate21poundsin1year, or triple his birth weight. Answers A, B, and C therefore are incorrect. A client is admitted with a Ewing's sarcoma. Which symptoms would be expected due to this tumor's location? ❍ A. Hemiplegia ❍ B. Aphasia ❍ C. Nausea ❍ D. Bonepain Correct Answer: AnswerDiscorrect.Sarcomaisatypeofbonecancer;therefore,bonepainwouldbe expected. Answers A, B, and C are not specific to this type of cancer and are incorrect. The nurse is caring for a client with epilepsy who is being treated with carbamazepine (Tegretol). Which laboratory value might indi- cate a serious side effect of this drug? ❍ A. Uric acid of 5mg/dL ❍ B.Hematocrit of 33% ❍ C.WBC 2,000 per cubic millimeter ❍ D.Platelets 150,000 per cubic millimeter Correct Answer: AnswerCiscorrect.Tegretolcansuppressthebonemarrowanddecreasethewhite blood cell count; thus, a lab value of WBC 2,000 per cubic millimeter indicates side effects of the drug. Answers A and D are within normal limits, and answer B is a lower limit of normal; therefore answers A, B, and D are incorrect. A 6-month-old client is admitted with possible intussuception. Which question during the nursing history is least helpful in obtaining information regarding this diagnosis? ❍ A."Tell me about his pain." ❍ B."What does his vomit look like?" ❍ C."Describe his usual diet." ❍ D."Have you noticed changes in his abdominal size?" Correct Answer: AnswerCiscorrect.Theleast-helpfulquestionsarethosedescribinghisusualdiet.A, B, and D are useful in determining the extent of disease process and, thus, are incor- rect. The nurse is assisting a client with diverticulosis to select appro- priate foods. Which food should be avoided? ❍ A.Bran ❍ B.Fresh peaches ❍ C.Cucumber salad ❍ D.Yeast rolls Correct Answer: AnswerCiscorrect.Theclientwithdiverticulitisshouldavoidfoodswithseeds.The foods in answers A, B, and D are allowed; in fact, bran cereal and fruit will help pre- vent constipation. A client has rectal cancer and is scheduled for an abdominal per- ineal resection. What should be the priority nursing care during the post-op period? ❍ A.Teaching how to irrigate the illeostomy ❍ B.Stopping electrolyte loss in the incisional area ❍ C.Encouraging a high-fiber diet ❍ D.Facilitating perineal wound drainage Correct Answer: AnswerDiscorrect.Theclientwithaperinealresectionwillhaveaperinealincision. Drains will be used to facilitate wound drainage. This will help prevent infection of the surgical site. The client will not have an illeostomy, as in answer A; he will have some electrolyte loss, but treatment is not focused on preventing the loss, so answer B is incorrect. A high-fiber diet, in answer C, is not ordered at this time. The nurse is performing discharge teaching on a client with diver- ticulitis who has been placed on a low-roughage diet. Which food would have to be eliminated from this client's diet? ❍ A.Roasted chicken ❍ B.Noodles ❍ C.Cooked broccoli ❍ D.Custard Correct Answer: AnswerCiscorrect.Theclientwithdiverticulitisshouldavoideatingfoodsthatare gas forming and that increase abdominal discomfort, such as cooked broccoli. Foods such as those listed in answers A, B, and D are allowed. [Show More]

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