NCLEX PN EXAM 4 ACTUAL EXAM 4 COMPLETE REAL QUESTIONS AND CORRECT ANSWERS

NCLEX-PN
The parent of a preschooler with chickenpox asks the nurse about measures to make t
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he child comfortable. The nurse instructs the parent to avoid administering aspirin or
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any other product that contains salicylates. When given to children with chickenpox,
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aspirin has been linked to which disorder?
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1. Guillain-Barré syndrome e




2. Rheumatic fever e




3. Reye's syndrome e




4. Scarlet fever – e e




Correct Answer: 3 e e




RATIONALES: Research shows a correlation between the use of aspirin during chic e e e e e e e e e e e


kenpox and the development of Reye's syndrome (a disorder characterized by brain a
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nd liver toxicity). Therefore, the nurse should instruct the parents to avoid administeri
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ng aspirin or other products that contain salicylates and to consult the physician or ph
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armacist before administering any medication to a child with chickenpox. No researc
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h has found a link between aspirin use, chickenpox, and the development of Guillain-
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Barré syndrome, rheumatic fever, or scarlet fever.
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A client is to have an epidural block to relieve labor pain. The nurse anticipates that th
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e anesthesiologist will inject the anesthetic agent into the:
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1. subarachnoid space. e




2. area between the subarachnoid space and the dura mater.
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3. area between the dura mater and the ligamentum flavum.
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4. ligamentum flavum. - Correct Answer: 3 e e e e e




RATIONALES: For an epidural block, the nurse should anticipate that the anesthesio e e e e e e e e e e e


logist will inject a local anesthetic agent into the epidural space, located
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,between the dura mater and the ligamentum flavum in the lumbar region of the spinal
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column. When administering a spinal block, the anesthesiologist injects the anestheti
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c agent into the subarachnoid space. The ligamentum flavum and the area between the
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subarachnoid space and the dura mater are inappropriate injection sites.
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The physician prescribes penicillin potassium oral suspension 56 mg/kg/day in four
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divided doses for a client with anorexia nervosa who weighs 25 kg. The medication d
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ispensed by the pharmacy contains a dosage strength of 125 mg/5 ml. How many mill
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iliters of solution should the nurse administer with each dose? –
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Correct Answer: 14 e e




RATIONALES: To determine the total daily dosage, set up the following proportion: e e e e e e e e e e e


25 kg/X = 1 kg/56 mg
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X = 1,400 mg.
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Next, divide the daily dosage by four doses to determine the dose to administer every 6
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hours:
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X = 1,400 mg/4 doses
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X = 350 mg/dose.
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The adolescent should receive 350 mg every 6 hours.
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Lastly, calculate the volume to give for each dose by setting up this proportion: X/350
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mg = 5 ml/125 mge e e e


X = 14 ml.
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The nurse must irrigate a gaping abdominal incision with sterile normal saline, using
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a piston syringe. How should the nurse proceed?
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1. Irrigate continuously until the solution becomes clear or all of the solution has be
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en used. e




2. Moisten the area around the wound with normal saline after the irrigation.
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3. Apply a wet-to-dry dressing to the wound after the irrigation.
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4. Rapidly instill a stream of irrigating solution into the wound. –
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Correct Answer: 1
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,RATIONALES: To wash away tissue debris and drainage effectively, the nurse shoul e e e e e e e e e e e


d irrigate the wound until the solution becomes clear or all of the solution has been use
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d. After the irrigation, the nurse should dry the area around the wound; moistening it p
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romotes microorganism growth and skin irritation. When the area is dry, the nurse sho
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uld apply a sterile dressing, rather than awet-to-
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dry dressing. The nurse always should instill the irrigating solution gently; rapid or for
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ceful instillation can damage tissues.
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As an adolescent is receiving care, he's inadvertently injured with a warm compress.
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The nurse completes an incident report based on the knowledge that identification of
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which of the following is a goal of the report?
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1. To reprimand the involved staff members for their actions
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2. To identify the learning needs of staff to prevent incident recurrences
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3. To reprimand the nurse-manager responsible for the unit
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4. To hold people accountable for their actions - Correct Answer: 2
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RATIONALES: The purpose of an incident report is threefold: to identify ways to pre e e e e e e e e e e e e e


vent incident recurrences, to identify patterns of care problems, and to identify facts s
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urrounding each incident. Incident reports aren't used to hold people accountable for t
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heir actions, to punish those involved in the incident, or to punish the nurse-
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manager responsible for the unit. e e e e




As a client progresses through pregnancy, she develops constipation. What is the prim
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ary cause of this problem during pregnancy?
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1. Decreased appetite e




2. Inadequate fluid intake e e

, 3. Prolonged gastric emptying e e




4. Reduced intestinal motility e e e


Correct Answer: 4 e e




RATIONALES: During pregnancy, hormonal changes and mechanical pressure redu
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ce motility in the small intestine, enhancing water absorption and promoting constipat
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ion. Although decreased appetite, inadequate fluid intake, and prolonged gastric empt
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ying may contribute to constipation, they aren't the primary cause.
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An adolescent with type 1 diabetes mellitus is experiencing a growth spurt. Which tre
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atment approach would be most effective for this client?
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1. Administering insulin once per day e e e e




2. Administering multiple doses of insulin e e e e




3. Limiting dietary fat intake e e e




4. Substituting an oral antidiabetic agent for insulin - Correct Answer: 2
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RATIONALES: During an adolescent growth spurt, a regimen of multiple insulin dos
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es achieves better control of the blood glucose level because it more closely simulates
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endogenous insulin release. A single daily dose of insulin wouldn't control this client'
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s blood glucose level as effectively. Limiting dietary fat intake wouldn't help the body
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use glucose at the cellular level. An adolescent with type 1 diabetes mellitus doesn't pr
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oduce insulin and therefore can't receive an oral antidiabetic agent instead of insulin.
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