1
Saunders NCLEX-PN A+ Graded Questions
and 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." - Correct 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
1
, 2
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
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.
2
, 3
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. - Correct 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
3
, 4
Content Area: Fundamental Skills: Fluids & Electrolytes
Priority Concepts: Clinical Judgment, Fluid and Electrolyte
Balance
Reference(s): deWit, Kumagai (2013), pp. 41-42.
743. The nurse is monitoring a client receiving glipizide
(Glucotrol). Which outcome indicates an ineffective response
from the medication?
1. A decrease in polyuria
2. A decrease in polyphagia
3. A fasting plasma glucose of 100 mg/dL
4. A glycosylated hemoglobin level of 12% - Correct Answer-
743. 4
Rationale: Glipizide (Glucotrol) 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 is within normal limits. However, glycosylated
hemoglobin of 12% indicates poor glycemic control.
Test-Taking Strategy: Focus on the subject, an ineffective
response to the medication. Recalling that glipizide is an oral
hypoglycemic agent tells you to look for an option that would
4
Saunders NCLEX-PN A+ Graded Questions
and 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." - Correct 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
1
, 2
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
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.
2
, 3
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. - Correct 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
3
, 4
Content Area: Fundamental Skills: Fluids & Electrolytes
Priority Concepts: Clinical Judgment, Fluid and Electrolyte
Balance
Reference(s): deWit, Kumagai (2013), pp. 41-42.
743. The nurse is monitoring a client receiving glipizide
(Glucotrol). Which outcome indicates an ineffective response
from the medication?
1. A decrease in polyuria
2. A decrease in polyphagia
3. A fasting plasma glucose of 100 mg/dL
4. A glycosylated hemoglobin level of 12% - Correct Answer-
743. 4
Rationale: Glipizide (Glucotrol) 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 is within normal limits. However, glycosylated
hemoglobin of 12% indicates poor glycemic control.
Test-Taking Strategy: Focus on the subject, an ineffective
response to the medication. Recalling that glipizide is an oral
hypoglycemic agent tells you to look for an option that would
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