The parent of a preschooler with chickenpox asks the
nurse about measures to make the child comfortable. The
nurse instructs the parent to avoid administering aspirin
or any other product that contains salicylates. When given
to children with chickenpox, aspirin has been linked to
which disorder?
Correct Answer: 3
RATIONALES: Research shows a correlation between the
1. Guillain-Barré syndrome use of aspirin during chickenpox and the development of
Reye's syndrome (a disorder characterized by brain and
liver toxicity). Therefore, the nurse should instruct the par-
ents to avoid administering aspirin or other products that
contain salicylates and to consult the physician or phar-
2. Rheumatic fever macist before administering any medication to a child with
chickenpox. No research has found a link between aspirin
use, chickenpox, and the development of Guillain-Barré
syndrome, rheumatic fever, or scarlet fever.
3. Reye's syndrome
4. Scarlet fever
A client is to have an epidural block to relieve labor pain.
The nurse anticipates that the anesthesiologist will inject
the anesthetic agent into the:
Correct Answer: 3
1. subarachnoid space.
, NCLEX-PN 3000 Questions with Verified Answers Graded A+
2. area between the subarachnoid space and the dura RATIONALES: For an epidural block, the nurse should an-
mater. ticipate that the anesthesiologist will inject a local anes-
thetic agent into the epidural space, located between the
dura mater and the ligamentum flavum in the lumbar
region of the spinal column. When administering a spinal
block, the anesthesiologist injects the anesthetic agent
3. area between the dura mater and the ligamentum
into the subarachnoid space. The ligamentum flavum and
flavum.
the area between the subarachnoid space and the dura
mater are inappropriate injection sites.
4. ligamentum flavum.
Correct Answer: 14
RATIONALES: To determine the total daily dosage, set up
the following proportion:
25 kg/X = 1 kg/56 mg
The physician prescribes penicillin potassium oral sus-
X = 1,400 mg.
pension 56 mg/kg/day in four divided doses for a client
Next, divide the daily dosage by four doses to determine
with anorexia nervosa who weighs 25 kg. The medication
the dose to administer every 6 hours:
dispensed by the pharmacy contains a dosage strength of
X = 1,400 mg/4 doses
125 mg/5 ml. How many milliliters of solution should the
X = 350 mg/dose.
nurse administer with each dose?
The adolescent should receive 350 mg every 6 hours.
Lastly, calculate the volume to give for each dose by setting
up this proportion:
X/350 mg = 5 ml/125 mg
X = 14 ml.
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The nurse must irrigate a gaping abdominal incision with
sterile normal saline, using a piston syringe. How should
the nurse proceed?
1. Irrigate continuously until the solution becomes clear
Correct Answer: 1
or all of the solution has been used.
RATIONALES: To wash away tissue debris and drainage
ettectively, the nurse should irrigate the wound until the
solution becomes clear or all of the solution has been
2. Moisten the area around the wound with normal saline used. After the irrigation, the nurse should dry the area
after the irrigation. around the wound; moistening it promotes microorgan-
ism growth and skin irritation. When the area is dry,
the nurse should apply a sterile dressing, rather than
awet-to-dry dressing. The nurse always should instill the
irrigating solution gently; rapid or forceful instillation can
3. Apply a wet-to-dry dressing to the wound after the damage tissues.
irrigation.
4. Rapidly instill a stream of irrigating solution into the
wound.
As an adolescent is receiving care, he's inadvertently in-
jured with a warm compress. The nurse completes an
incident report based on the knowledge that identification
of which of the following is a goal of the report?
, NCLEX-PN 3000 Questions with Verified Answers Graded A+
1. To reprimand the involved statt members for their ac-
tions
Correct Answer: 2
2. To identify the learning needs of statt to prevent incident
recurrences RATIONALES: The purpose of an incident report is three-
fold: to identify ways to prevent incident recurrences, to
identify patterns of care problems, and to identify facts
surrounding each incident. Incident reports aren't used to
hold people accountable for their actions, to punish those
3. To reprimand the nurse-manager responsible for the involved in the incident, or to punish the nurse-manager
unit responsible for the unit.
4. To hold people accountable for their actions
As a client progresses through pregnancy, she develops
constipation. What is the primary cause of this problem
during pregnancy?
Correct Answer: 4
1. Decreased appetite RATIONALES: During pregnancy, hormonal changes and
mechanical pressure reduce motility in the small intestine,
enhancing water absorption and promoting constipation.
Although decreased appetite, inadequate fluid intake, and
2. Inadequate fluid intake