NCLEX-PN Comprehensive Test Exam And Answer #1.

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 & 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 3. We need to maintain respiratory precautions & a quiet environment for at least 2 weeks A client enters the emergency department confused, twitching, & having seizures. His family states he recently was placed on corticosteroids for arthritis & was feeling better & exercising daily. Upon assessment, he has flushed skin, dry mucous membranes, an elevated temperature, & poor skin turgor. His serum sodium level is 172 mEq/L. Which interventions would the health care provider likely prescribe? select all that apply. 1. Monitor the vital signs 2. Monitor intake & output 3. Increase water intake orally 4. Monitor the electrolyte levels 5. Provide a sodium-reduced diet 6. Administer sodium replacements - correct answer 1. Monitor the vital signs 2. Monitor intake & output 3. Increase water intake orally 4. Monitor the electrolyte levels 5. Provide a sodium-reduced diet 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 4. A glycosylated hemoglobin level of 12% The nurse is reinforcing discharge instructions to a client receiving sulfisoxazole. Which should be included in the plan of care for instructions? 1. Maintain a high fluid intake 2. Discontinue the medication when feeling better 3. If the urine turns dark brown, call the health care provider immediately 4. Decrease the dosage when symptoms are improving to prevent an allergic response - correct answer 1. Maintain a high fluid intake Before administering an intermittent tube feeding through a nasogastric tube, the nurse checks for gastric residual volume. Which is the best rationale for checking gastric residual volume before administering the tube feeding? 1. Observe the digestion of formula 2. Check fluid & electrolyte status 3. Evaluate absorption of the last feeding 4. Confirm proper nasogastric tube placement - correct answer 3. Evaluate absorption of the last feeding A postoperative client requests medication for flatulence (gas pains). Which medication from the following PRN list should the nurse administer to this client 1. Ondansetron (zofran) 2. Simethicone (mylicon) 3. Acetaminophen (tylenol) 4. Magnesium hydroxide ( milk of mag) - correct answer 2. Simethicone (mylicon) A client is admitted to the hospital with a diagnosis of major depression. During the admission interview, the nurse determines that a major concern is the client's altered nutrition related to poor nutritional intake. Which nursing intervention related to altered nutrition should be the initial choice? 1. Weigh the client three times per week, before breakfast. 2. Explain to the client the importance of a good nutritional intake 3. Report the nutritional concern to the psychiatrist & obtain a nutritional consult as soon as possible 4. Offer the client several small, frequent meals daily, and schedule brief nursing interactions with the client during these times - correct answer 4. Offer the client several small, frequent meals daily, and schedule brief nursing interactions with the client during these times A client received 20 units of NPH insulin subcutaneously at 8:00 am. The nurse should check the client for a potential hypoglycemic reaction at which time?