NCLEX-PN PACKAGE DEAL EXAM - COMPLETE
QUESTIONS
AND DETAILED SOLUTIONS LATEST UPDATE THIS
YEAR JUST RELEASED
Question 1: The nurse is caring for a client at 12 weeks gestation
who has a rubella titer status of nonimmune. Which of the following
action should the nurse anticipate implementing?
A. administering measles-mumps-rubella (MMR) vaccine now
B. administering measles-mumps-rubella (MMR) vaccine immediately
postpartum
C. administering measles-mumps-rubella (MMR) vaccine in the third
trimester
D. informing the client that a measles-mumps-rubella (MMR) vaccine
is not indicated.
Answer:
B
Recommended vaccines during pregnancy: Tdap, INACTIVATED influenza,
Rho(D) immunoglobulin
Contra: HPV, MMR, live activated influenza, varicela
Question 2: A negative or non immune response shows that the
client is susceptible to rubella and requires vaccine. Live vaccine
are contraindicated during pregnancy as they can be teratogenic
for the fetus. The nurse is observing a staff member care for a
newborn with a myelomeningocele. The nurse should intervene if a
staff member is observed.
A. obtaining a rectal temp
B. placing the newborn in a prone position
C. avoiding the use of diapers on the newborn
, D. covering the sac with moist, sterile dressing
Answer:
A
myelomeningocele is open spina bifida, rectal temps can cause rectal prolapse
prone to prevent rupture, no diapers, a sterile dressing until surgical repair can
occur
Question 3: A client who is pregnant at 30 weeks gestation comes
to the prenatal clinic. Which of the following vaccines may be
administered safely at this prenatal visit? SATA
A. influenza injection
B. influenza nasal spray
C. measles, mumps, and rubella (MMR)
D. tetanus, diphtheria, and pertussis
E. varicella
Answer:
A, D
Question 4: The nurse has attended a staff education program
about mediation refusal. Which of the following statements by the
nurse would indicate a understanding of the program?
A. refused doses of an opiod should be disposed of in a
puncture-resistant bin at the clients bedside
B. client's should be offered previously refused medications again
after the nurse has explored and addressed the reasons for refusal.
C. refused doses of an antibiotic do not need to be documented if the
nurse notifies the client's HCP
D. client's do not have the right to refuse medications if the consent
for treatment was signed on admission
Answer:
B
,Question 5: Which components are used in determining the
standards of professional nursing practice? SATA
A. Care given with good intentions to the best of one's ability
B. Clinical practice statements of professional organizations
C. Health care institution's policies and procedures
D. Nurse Practice Act of the state or province/territory
E. Nurse's usual custom and practice
Answer:
B, C, D
The standards of nursing care are defined by what reasonable, prudent nurses
would do in specific circumstances. Based on objective, third-party authoritative
sources, including literature, laws (Nursing Practice Act), and professional
organizations.
Question 6: An individuals actions do not replace the universal
standard and it is not INTENTION based. The nurse is reinforcing
teaching to a client with Raynaud phenomenon about ways to
prevent recurrent episodes. Which instructions should the nurse
include? SATA
A. Avoid excess caffeine
B. Immerse hands in cold water
C. Practice yoga or tai chi
D. Refrain from using tobacco products
E. Wear gloves when handling cold objects
Answer:
A, C, D, E
Raynaud is a vasospastic disorder resulting in vascular response to cold temps or
emotional stress. Women ages 15-40. Treat by immersing hands in warm water.
CCBs may be prescribed to relax smooth muscle and prevent episodes
, Question 7: The nurse is preparing to administer a scheduled dose
of metoclopramide IV to a client with diabetic gastroparesis. Which
clinical findings causes the nurse to question the prescription?
A. Diarrhea
B. Frequent burping
C. Headache
D. Sucking lip motions
Answer:
D
Metoclopramide is an antiemetic used to treat n/v for gastroparesis by promoting
gastric emptying. Extended dosing may lead to tardive dyskinesia, a movement
disorder that is characterized by uncontrolled motions.
FACE: lip movement, tongue movement, grimace, brown twitch, excess blinking
EXTREMITIES: foot tap, hand wringing, tremor
NECK & TORSO: rocking, toricollin (neck flexion/extension)
Question 8: A postoperative client who is receiving continuous
enteral feedings via a NG tube has become dyspneic with a
productive cough, and the nurse auscultates crackles and
diminished breath sounds in lung bases. Which action is
appropriate at this time?
A. Administer inhaled bronchodilator
B. Check marked insertion depth of the tube
C. Request a prescription for a diuretic
D. Start the client n incentive spirometer
Answer:
B
If the client presents with symptoms of aspiration pneumonia stop the feedings
immediately and check tube placement.
Question 9: The nurse at the prenatal clinic is reinforcing education
to a client who is HIV positive. Which information is appropriate for
QUESTIONS
AND DETAILED SOLUTIONS LATEST UPDATE THIS
YEAR JUST RELEASED
Question 1: The nurse is caring for a client at 12 weeks gestation
who has a rubella titer status of nonimmune. Which of the following
action should the nurse anticipate implementing?
A. administering measles-mumps-rubella (MMR) vaccine now
B. administering measles-mumps-rubella (MMR) vaccine immediately
postpartum
C. administering measles-mumps-rubella (MMR) vaccine in the third
trimester
D. informing the client that a measles-mumps-rubella (MMR) vaccine
is not indicated.
Answer:
B
Recommended vaccines during pregnancy: Tdap, INACTIVATED influenza,
Rho(D) immunoglobulin
Contra: HPV, MMR, live activated influenza, varicela
Question 2: A negative or non immune response shows that the
client is susceptible to rubella and requires vaccine. Live vaccine
are contraindicated during pregnancy as they can be teratogenic
for the fetus. The nurse is observing a staff member care for a
newborn with a myelomeningocele. The nurse should intervene if a
staff member is observed.
A. obtaining a rectal temp
B. placing the newborn in a prone position
C. avoiding the use of diapers on the newborn
, D. covering the sac with moist, sterile dressing
Answer:
A
myelomeningocele is open spina bifida, rectal temps can cause rectal prolapse
prone to prevent rupture, no diapers, a sterile dressing until surgical repair can
occur
Question 3: A client who is pregnant at 30 weeks gestation comes
to the prenatal clinic. Which of the following vaccines may be
administered safely at this prenatal visit? SATA
A. influenza injection
B. influenza nasal spray
C. measles, mumps, and rubella (MMR)
D. tetanus, diphtheria, and pertussis
E. varicella
Answer:
A, D
Question 4: The nurse has attended a staff education program
about mediation refusal. Which of the following statements by the
nurse would indicate a understanding of the program?
A. refused doses of an opiod should be disposed of in a
puncture-resistant bin at the clients bedside
B. client's should be offered previously refused medications again
after the nurse has explored and addressed the reasons for refusal.
C. refused doses of an antibiotic do not need to be documented if the
nurse notifies the client's HCP
D. client's do not have the right to refuse medications if the consent
for treatment was signed on admission
Answer:
B
,Question 5: Which components are used in determining the
standards of professional nursing practice? SATA
A. Care given with good intentions to the best of one's ability
B. Clinical practice statements of professional organizations
C. Health care institution's policies and procedures
D. Nurse Practice Act of the state or province/territory
E. Nurse's usual custom and practice
Answer:
B, C, D
The standards of nursing care are defined by what reasonable, prudent nurses
would do in specific circumstances. Based on objective, third-party authoritative
sources, including literature, laws (Nursing Practice Act), and professional
organizations.
Question 6: An individuals actions do not replace the universal
standard and it is not INTENTION based. The nurse is reinforcing
teaching to a client with Raynaud phenomenon about ways to
prevent recurrent episodes. Which instructions should the nurse
include? SATA
A. Avoid excess caffeine
B. Immerse hands in cold water
C. Practice yoga or tai chi
D. Refrain from using tobacco products
E. Wear gloves when handling cold objects
Answer:
A, C, D, E
Raynaud is a vasospastic disorder resulting in vascular response to cold temps or
emotional stress. Women ages 15-40. Treat by immersing hands in warm water.
CCBs may be prescribed to relax smooth muscle and prevent episodes
, Question 7: The nurse is preparing to administer a scheduled dose
of metoclopramide IV to a client with diabetic gastroparesis. Which
clinical findings causes the nurse to question the prescription?
A. Diarrhea
B. Frequent burping
C. Headache
D. Sucking lip motions
Answer:
D
Metoclopramide is an antiemetic used to treat n/v for gastroparesis by promoting
gastric emptying. Extended dosing may lead to tardive dyskinesia, a movement
disorder that is characterized by uncontrolled motions.
FACE: lip movement, tongue movement, grimace, brown twitch, excess blinking
EXTREMITIES: foot tap, hand wringing, tremor
NECK & TORSO: rocking, toricollin (neck flexion/extension)
Question 8: A postoperative client who is receiving continuous
enteral feedings via a NG tube has become dyspneic with a
productive cough, and the nurse auscultates crackles and
diminished breath sounds in lung bases. Which action is
appropriate at this time?
A. Administer inhaled bronchodilator
B. Check marked insertion depth of the tube
C. Request a prescription for a diuretic
D. Start the client n incentive spirometer
Answer:
B
If the client presents with symptoms of aspiration pneumonia stop the feedings
immediately and check tube placement.
Question 9: The nurse at the prenatal clinic is reinforcing education
to a client who is HIV positive. Which information is appropriate for
