NCLEX-PN Exam Review V2
• Pilocarpine hydrochloride (Isopto Carpine) is prescribed for the client withglaucoma.
Which medication should the nurse plan to have available in the event of systemic toxicity?:
Atropine sulfate
Rationale:
Systemic absorption of pilocarpine hydrochloride can produce toxicity and includes
manifestations of vertigo, bradycardia, tremors, hypotension, and seizures. Atropine sulfate must
be available in the event of systemic toxicity. Pindolol, timolol maleate, and carteolol
hydrochloride are ²-blockers.
• A client has undergone subtotal gastrectomy and the nurse is preparing the client for
discharge. Which item should be included when reinforcing instructions to the client about
ongoing self-management?: Smaller, more fre-quent meals should be eaten.
Rationale:
Following gastric surgery, the client should eat smaller, more frequent meals to facilitate
digestion. The client should resume activity gradually and should minimizestressors to prevent
recurrence of symptoms. The client does require ongoing medical supervision and evaluation.
• A client has asymptomatic diverticular disease. Which type of diet shouldthe nurse
anticipate being prescribed?: High-fiber diet
Rationale:
A high-fiber diet is the diet of choice for asymptomatic diverticular disease to help prevent
straining from constipation. A high-iron diet is for clients with anemia to helpmake
hemoglobin. A low-purine diet is for clients with gout to prevent formation of stones and
crystals. Hypertensive clients and clients with cardiac problems may require a low-sodium
diet to prevent increased fluid volume.
• The nurse is assisting in developing a plan of care for a client in the fourthstage of labor
who received an epidural. Which problem is most likely to occurduring this stage?: Urinary
retention caused by the loss of sensation to void and rapid bladder filling
Rationale:
The fourth stage of labor is the period of time from 1 to 4 hours after delivery, whenthe
,woman's body begins to readjust and relax. Options 1 and 2 relate to the first stage of labor.
Option 3 relates to the second stage of labor. Option 4 is related to the third and fourth stages
of labor.
• A clinic nurse is reviewing the record of a client recently diagnosed with acataract.Which
clinical manifestation associated with this disorder should thenurse expect to be documented in
the client's record?: Painless, progressive loss of vision
Rationale:
A cataract is any opacity of the crystalline lens of the eye. The classic symptom of cataracts is
painless progressive loss of vision in one or both eyes. Some individualsalso complain of glare
from bright lights. Occasionally pain can result when the lensbecomes swollen and blocks the
normal flow of aqueous fluid, causing increased intraocular pressure. Color blindness is not an
associated symptom.
• The nurse-midwife is conducting a session on the process of fertilization with a group of
nursing students. The nurse-midwife asks a nursing student to identify the structure in which
fertilization of an ovum takes place. The student answers correctly by identifying which
location?: Fallopian tube
Rationale:
Fallopian tubes, also called oviducts, are 8 to 14 cm long and quite narrow. Thefallopian tubes
are a pathway for the ovum between the ovary and the uterus.
Fertilization occurs in the fallopian tube.
• The nurse should include which information when reinforcing home careinstructions for a
client who has peptic ulcer disease?: Learn to use stress reduction techniques.
Rationale:
Identifying and reducing stress is essential to a comprehensive ulcer management plan. The
client also should avoid intake of foods that aggravate pain, quit smoking,and avoid irritants
such as NSAIDs. Antibiotic therapy often cures the client of this problem in many instances.
• The nurse is caring for a postoperative parathyroidectomy client. Whichwould require the
nurse's immediate attention?: Laryngeal stridor
Rationale:
, During the postoperative period, the nurse carefully observes the client for signsof
hemorrhage, which causes swelling and the compression of adjacent tissue.
Laryngeal stridor is a harsh, high-pitched sound heard on inspiration and expirationthat is
caused by the compression of the trachea and that leads to respiratory distress. It is an acute
emergency situation that requires immediate attention to avoidthe complete obstruction of the
airway.
• The nurse sees another nurse administer an incorrect medication to a client. The nurse
who administered the incorrect medication does not reportthe error. Which would be the initial
action by the nurse who observed the error?: Ask the nurse if he or she intends to report the
error.
Rationale:
The initial action by the nurse who observed the error would be to ask the nurse if he or she
intends to report the error. To ensure client safety, all errors need to be reported. The client also
needs to be assessed immediately. An incident reportneeds to be completed by the nurse who
administered the incorrect medication.
The appropriate documentation also needs to be made in the client's record by the nurse who
administered the incorrect medication. If the nurse who made the error indicates that the error
will not be reported, then it may be necessary to contact thesupervisor.
• The nurse should anticipate that which medication is the most likely to beprescribed
prophylactically for a child with spina bifida (myelomeningocele) who has a neurogenic
bladder?: Sulfisoxazole
Rationale:
A neurogenic bladder prevents the bladder from completely emptying because of
the decrease in muscle tone. The most likely medication to be prescribed to preventurinary tract
infection would be an antibiotic. A common prescribed medication is sulfisoxazole.
Prednisone relieves allergic reactions and inflammation rather than preventing infection.
Furosemide promotes diuresis and decreases edema causedby heart failure. IVIG assists with
antibody production in immunocompromised clients.
• The nurse is caring for a client diagnosed with catatonic stupor. The clientis lying on the
bed, with the body pulled into a fetal position. The appropriatenursing intervention is which?:
Sit beside the client in silence and verbalize occasional open-ended questions.
Rationale:
• Pilocarpine hydrochloride (Isopto Carpine) is prescribed for the client withglaucoma.
Which medication should the nurse plan to have available in the event of systemic toxicity?:
Atropine sulfate
Rationale:
Systemic absorption of pilocarpine hydrochloride can produce toxicity and includes
manifestations of vertigo, bradycardia, tremors, hypotension, and seizures. Atropine sulfate must
be available in the event of systemic toxicity. Pindolol, timolol maleate, and carteolol
hydrochloride are ²-blockers.
• A client has undergone subtotal gastrectomy and the nurse is preparing the client for
discharge. Which item should be included when reinforcing instructions to the client about
ongoing self-management?: Smaller, more fre-quent meals should be eaten.
Rationale:
Following gastric surgery, the client should eat smaller, more frequent meals to facilitate
digestion. The client should resume activity gradually and should minimizestressors to prevent
recurrence of symptoms. The client does require ongoing medical supervision and evaluation.
• A client has asymptomatic diverticular disease. Which type of diet shouldthe nurse
anticipate being prescribed?: High-fiber diet
Rationale:
A high-fiber diet is the diet of choice for asymptomatic diverticular disease to help prevent
straining from constipation. A high-iron diet is for clients with anemia to helpmake
hemoglobin. A low-purine diet is for clients with gout to prevent formation of stones and
crystals. Hypertensive clients and clients with cardiac problems may require a low-sodium
diet to prevent increased fluid volume.
• The nurse is assisting in developing a plan of care for a client in the fourthstage of labor
who received an epidural. Which problem is most likely to occurduring this stage?: Urinary
retention caused by the loss of sensation to void and rapid bladder filling
Rationale:
The fourth stage of labor is the period of time from 1 to 4 hours after delivery, whenthe
,woman's body begins to readjust and relax. Options 1 and 2 relate to the first stage of labor.
Option 3 relates to the second stage of labor. Option 4 is related to the third and fourth stages
of labor.
• A clinic nurse is reviewing the record of a client recently diagnosed with acataract.Which
clinical manifestation associated with this disorder should thenurse expect to be documented in
the client's record?: Painless, progressive loss of vision
Rationale:
A cataract is any opacity of the crystalline lens of the eye. The classic symptom of cataracts is
painless progressive loss of vision in one or both eyes. Some individualsalso complain of glare
from bright lights. Occasionally pain can result when the lensbecomes swollen and blocks the
normal flow of aqueous fluid, causing increased intraocular pressure. Color blindness is not an
associated symptom.
• The nurse-midwife is conducting a session on the process of fertilization with a group of
nursing students. The nurse-midwife asks a nursing student to identify the structure in which
fertilization of an ovum takes place. The student answers correctly by identifying which
location?: Fallopian tube
Rationale:
Fallopian tubes, also called oviducts, are 8 to 14 cm long and quite narrow. Thefallopian tubes
are a pathway for the ovum between the ovary and the uterus.
Fertilization occurs in the fallopian tube.
• The nurse should include which information when reinforcing home careinstructions for a
client who has peptic ulcer disease?: Learn to use stress reduction techniques.
Rationale:
Identifying and reducing stress is essential to a comprehensive ulcer management plan. The
client also should avoid intake of foods that aggravate pain, quit smoking,and avoid irritants
such as NSAIDs. Antibiotic therapy often cures the client of this problem in many instances.
• The nurse is caring for a postoperative parathyroidectomy client. Whichwould require the
nurse's immediate attention?: Laryngeal stridor
Rationale:
, During the postoperative period, the nurse carefully observes the client for signsof
hemorrhage, which causes swelling and the compression of adjacent tissue.
Laryngeal stridor is a harsh, high-pitched sound heard on inspiration and expirationthat is
caused by the compression of the trachea and that leads to respiratory distress. It is an acute
emergency situation that requires immediate attention to avoidthe complete obstruction of the
airway.
• The nurse sees another nurse administer an incorrect medication to a client. The nurse
who administered the incorrect medication does not reportthe error. Which would be the initial
action by the nurse who observed the error?: Ask the nurse if he or she intends to report the
error.
Rationale:
The initial action by the nurse who observed the error would be to ask the nurse if he or she
intends to report the error. To ensure client safety, all errors need to be reported. The client also
needs to be assessed immediately. An incident reportneeds to be completed by the nurse who
administered the incorrect medication.
The appropriate documentation also needs to be made in the client's record by the nurse who
administered the incorrect medication. If the nurse who made the error indicates that the error
will not be reported, then it may be necessary to contact thesupervisor.
• The nurse should anticipate that which medication is the most likely to beprescribed
prophylactically for a child with spina bifida (myelomeningocele) who has a neurogenic
bladder?: Sulfisoxazole
Rationale:
A neurogenic bladder prevents the bladder from completely emptying because of
the decrease in muscle tone. The most likely medication to be prescribed to preventurinary tract
infection would be an antibiotic. A common prescribed medication is sulfisoxazole.
Prednisone relieves allergic reactions and inflammation rather than preventing infection.
Furosemide promotes diuresis and decreases edema causedby heart failure. IVIG assists with
antibody production in immunocompromised clients.
• The nurse is caring for a client diagnosed with catatonic stupor. The clientis lying on the
bed, with the body pulled into a fetal position. The appropriatenursing intervention is which?:
Sit beside the client in silence and verbalize occasional open-ended questions.
Rationale:
