NCLEX-PN 3000 Verified Multiple Choice and Conceptual Actual Emended Exam
Questions With Reviewed 100% Correct Detailed Answers
Guaranteed Pass!!Current Update
School-Age Child
A child with diabetes insipidus receives
Correct Answer: 1
desmopressin acetate (DDAVP). When
RATIONALES: The primary action of
evaluating for therapeutic effectiveness,
DDAVP is to stimulate water reabsorp-
the nurse would interpret which finding
tion by the kidneys, thereby decreasing
as a positive response to this drug?
the urine output. DDAVP has no effect on
1. Decreased urine output glucose levels, blood pressure, or nau-
sea.
2. Increased urine glucose level
3. Decreased blood pressure
4. Relief of nausea
Correct Answer: 1
Intrapartum Period RATIONALES: Having the client void can
determine whether the boggy, deviated
When assessing a client who has just fundus results from a full bladder — the
delivered a neonate, the nurse finds that most common cause of these fundal find-
the fundus is boggy and deviated to the ings. Vital sign assessment is unneces-
right. What should the nurse do? sary unless the nurse suspects hemor-
rhage from delayed involution. Evalua-
1. Have the client void. tion of the lochia is done to detect pos-
2. Assess the client's vital signs. sible hemorrhage. If the uterus remains
3. Evaluate lochia characteristics. boggy after the client voids, or if hem-
4. Massage the fundus. orrhage is suspected, the nurse should
massage the fundus.
Basic Physical Care
In a client who had major surgery 5 days
ago, which data collection finding would
be the best indication of a wound infec-
tion?
1. Complaints of deep, sharp incisional
pain
2. Evidence of uneven wound edges
3. Purulent wound drainage
4. Oral temperature of 100.6° F (38.1° C)
ANSWER #4
RATIONALES: Caput succedaneum
refers to a vaguely outlined area of scalp
, NCLEX-PN 3000 Verified Multiple Choice and Conceptual Actual Emended Exam
Questions With Reviewed 100% Correct Detailed Answers
Guaranteed Pass!!Current Update
edema that crosses the suture line and
typically clears within a few days after
When collecting data on a neonate, the
birth. Cephalhematoma is a swelling of
nurse observes a vaguely outlined area
the head that results from subcutaneous
of scalp edema. Which term should the
bleeding caused by pressure exerted on
nurse use when documenting this obser-
the soft tissues during delivery; it's char-
vation?
acterized by sharply demarcated bound-
1. Cephalhematoma
aries that don't cross the suture lines.
2. Petechiae
3. Subdural hematoma Petechiae are minute, circumscribed, he-
morrhagic areas of the skin. A subdural
4. Caput succedaneum
hematoma is a collection of blood be-
tween the dura and the brain.
Psychotic Disorders
A 50-year-old male client is hospitalized
in a psychiatric unit for treatment of an
acute phase of paranoid schizophrenia
with delusions of persecution. At the end
of her shift, a licensed practical nurse
reports the client's status to a registered
nurse. Which observation by the licensed
practical nurse indicates that the client's
condition is improving?
1. The client sits and stares at the televi-
sion for several hours.
2. After shaving and showering, the client
reports that the voices have been quiet
for several days.
3. The client reports that the television
transmits thoughts to his mind less fre-
quently than it did before.
4. The client searches his room for hid-
den transmitters.
ANSWER 2
Preschooler RATIONALES: Expiratory wheezing is
For a child who's admitted to the emer- common during an acute asthma attack
gency department with an acute asthma and results from narrowing of the air-
attack, nursing data collection is most way caused by edema. Acute asthma
rarely causes apneic periods. Inspirato-
, NCLEX-PN 3000 Verified Multiple Choice and Conceptual Actual Emended Exam
Questions With Reviewed 100% Correct Detailed Answers
Guaranteed Pass!!Current Update
ry stridor more commonly accompanies
likely to reveal: croup. Acute asthma is more likely to
1. apneic periods. cause adventitious breath sounds than
2. expiratory wheezing. absent breath sounds; however, adven-
3. inspiratory stridor. titious sounds are an ominous sign be-
4. absent breath sounds. cause the client is unable to exchange
air.
Preschooler
The physician diagnoses leukemia in a
child, age 4, who complains of being Correct Answer: 2
tired and sleeps most of the day. Which
RATIONALES: A child with leukemia may
nursing diagnosis reflects the nurse's un-
experience anemia from bone marrow
derstanding of the pathophysiology be-
depression, such as from chemotherapy
hind leukemia?
or replacement of normal bone marrow
1. Ineffective airway clearance related to
elements by immature white blood cells.
fatigue
Anemia results in fatigue, lack of energy,
2. Activity intolerance related to anemia
and activity intolerance. The information
3. Imbalanced nutrition: More than body
given in the question doesn't support the
requirements related to lack of activity
other diagnoses
4. Ineffective cerebral tissue perfusion
related to central nervous system infiltra-
tion by leukemic cells
Correct Answer: 1
RATIONALES: Vision changes, such as
Neurosensory Disorders
diplopia, nystagmus, and blurred vision,
The nurse is collecting data on a
are symptoms of multiple sclerosis. Deep
38-year-old client diagnosed with mul-
tendon reflexes may be increased or hy-
tiple sclerosis. Which of the following
peractive — not absent. Babinski's sign
symptoms would the nurse expect to
may be positive. Tremors at rest aren't
find?
characteristic of multiple sclerosis; how-
1. Vision changes
ever, intentional tremors, or those oc-
2. Absent deep tendon reflexes
curring with purposeful voluntary move-
3. Tremors at rest
ment, are common in clients with multiple
4. Flaccid muscles
sclerosis. Affected muscles are spastic,
rather than flaccid
Correct Answer: 4
RATIONALES: The best intervention is
for the client to sit in a warm sitz bath
Questions With Reviewed 100% Correct Detailed Answers
Guaranteed Pass!!Current Update
School-Age Child
A child with diabetes insipidus receives
Correct Answer: 1
desmopressin acetate (DDAVP). When
RATIONALES: The primary action of
evaluating for therapeutic effectiveness,
DDAVP is to stimulate water reabsorp-
the nurse would interpret which finding
tion by the kidneys, thereby decreasing
as a positive response to this drug?
the urine output. DDAVP has no effect on
1. Decreased urine output glucose levels, blood pressure, or nau-
sea.
2. Increased urine glucose level
3. Decreased blood pressure
4. Relief of nausea
Correct Answer: 1
Intrapartum Period RATIONALES: Having the client void can
determine whether the boggy, deviated
When assessing a client who has just fundus results from a full bladder — the
delivered a neonate, the nurse finds that most common cause of these fundal find-
the fundus is boggy and deviated to the ings. Vital sign assessment is unneces-
right. What should the nurse do? sary unless the nurse suspects hemor-
rhage from delayed involution. Evalua-
1. Have the client void. tion of the lochia is done to detect pos-
2. Assess the client's vital signs. sible hemorrhage. If the uterus remains
3. Evaluate lochia characteristics. boggy after the client voids, or if hem-
4. Massage the fundus. orrhage is suspected, the nurse should
massage the fundus.
Basic Physical Care
In a client who had major surgery 5 days
ago, which data collection finding would
be the best indication of a wound infec-
tion?
1. Complaints of deep, sharp incisional
pain
2. Evidence of uneven wound edges
3. Purulent wound drainage
4. Oral temperature of 100.6° F (38.1° C)
ANSWER #4
RATIONALES: Caput succedaneum
refers to a vaguely outlined area of scalp
, NCLEX-PN 3000 Verified Multiple Choice and Conceptual Actual Emended Exam
Questions With Reviewed 100% Correct Detailed Answers
Guaranteed Pass!!Current Update
edema that crosses the suture line and
typically clears within a few days after
When collecting data on a neonate, the
birth. Cephalhematoma is a swelling of
nurse observes a vaguely outlined area
the head that results from subcutaneous
of scalp edema. Which term should the
bleeding caused by pressure exerted on
nurse use when documenting this obser-
the soft tissues during delivery; it's char-
vation?
acterized by sharply demarcated bound-
1. Cephalhematoma
aries that don't cross the suture lines.
2. Petechiae
3. Subdural hematoma Petechiae are minute, circumscribed, he-
morrhagic areas of the skin. A subdural
4. Caput succedaneum
hematoma is a collection of blood be-
tween the dura and the brain.
Psychotic Disorders
A 50-year-old male client is hospitalized
in a psychiatric unit for treatment of an
acute phase of paranoid schizophrenia
with delusions of persecution. At the end
of her shift, a licensed practical nurse
reports the client's status to a registered
nurse. Which observation by the licensed
practical nurse indicates that the client's
condition is improving?
1. The client sits and stares at the televi-
sion for several hours.
2. After shaving and showering, the client
reports that the voices have been quiet
for several days.
3. The client reports that the television
transmits thoughts to his mind less fre-
quently than it did before.
4. The client searches his room for hid-
den transmitters.
ANSWER 2
Preschooler RATIONALES: Expiratory wheezing is
For a child who's admitted to the emer- common during an acute asthma attack
gency department with an acute asthma and results from narrowing of the air-
attack, nursing data collection is most way caused by edema. Acute asthma
rarely causes apneic periods. Inspirato-
, NCLEX-PN 3000 Verified Multiple Choice and Conceptual Actual Emended Exam
Questions With Reviewed 100% Correct Detailed Answers
Guaranteed Pass!!Current Update
ry stridor more commonly accompanies
likely to reveal: croup. Acute asthma is more likely to
1. apneic periods. cause adventitious breath sounds than
2. expiratory wheezing. absent breath sounds; however, adven-
3. inspiratory stridor. titious sounds are an ominous sign be-
4. absent breath sounds. cause the client is unable to exchange
air.
Preschooler
The physician diagnoses leukemia in a
child, age 4, who complains of being Correct Answer: 2
tired and sleeps most of the day. Which
RATIONALES: A child with leukemia may
nursing diagnosis reflects the nurse's un-
experience anemia from bone marrow
derstanding of the pathophysiology be-
depression, such as from chemotherapy
hind leukemia?
or replacement of normal bone marrow
1. Ineffective airway clearance related to
elements by immature white blood cells.
fatigue
Anemia results in fatigue, lack of energy,
2. Activity intolerance related to anemia
and activity intolerance. The information
3. Imbalanced nutrition: More than body
given in the question doesn't support the
requirements related to lack of activity
other diagnoses
4. Ineffective cerebral tissue perfusion
related to central nervous system infiltra-
tion by leukemic cells
Correct Answer: 1
RATIONALES: Vision changes, such as
Neurosensory Disorders
diplopia, nystagmus, and blurred vision,
The nurse is collecting data on a
are symptoms of multiple sclerosis. Deep
38-year-old client diagnosed with mul-
tendon reflexes may be increased or hy-
tiple sclerosis. Which of the following
peractive — not absent. Babinski's sign
symptoms would the nurse expect to
may be positive. Tremors at rest aren't
find?
characteristic of multiple sclerosis; how-
1. Vision changes
ever, intentional tremors, or those oc-
2. Absent deep tendon reflexes
curring with purposeful voluntary move-
3. Tremors at rest
ment, are common in clients with multiple
4. Flaccid muscles
sclerosis. Affected muscles are spastic,
rather than flaccid
Correct Answer: 4
RATIONALES: The best intervention is
for the client to sit in a warm sitz bath
