NCLEX-PN 3000 exam with solutions

NCLEX-PN 3000 exam with solutions
School-Age |Child
|

A |child |with |diabetes |insipidus |receives |desmopressin |acetate |(DDAVP). |When |evaluating |for
|therapeutic |effectiveness, |the |nurse |would |interpret |which |finding |as |a |positive |response |to

|this |drug? |




1. |Decreased |urine |output |
2. |Increased |urine |glucose |level |
3. |Decreased |blood |pressure |
4. |Relief |of |nausea |- |Correct |Answer: |1 |
RATIONALES: |The |primary |action |of |DDAVP |is |to |stimulate |water |reabsorption |by |the |kidneys,
|thereby |decreasing |the |urine |output. |DDAVP |has |no |effect |on |glucose |levels, |blood |pressure,

|or |nausea.




Intrapartum |Period

When |assessing |a |client |who |has |just |delivered |a |neonate, |the |nurse |finds |that |the |fundus |is
|boggy |and |deviated |to |the |right. |What |should |the |nurse |do? |




1. |Have |the |client |void. |
2. |Assess |the |client's |vital |signs. |
3. |Evaluate |lochia |characteristics. |
4. |Massage |the |fundus. |- |Correct |Answer: |1 |
RATIONALES: |Having |the |client |void |can |determine |whether |the |boggy, |deviated |fundus
|results |from |a |full |bladder |— |the |most |common |cause |of |these |fundal |findings. |Vital |sign

|assessment |is |unnecessary |unless |the |nurse |suspects |hemorrhage |from |delayed |involution.

|Evaluation |of |the |lochia |is |done |to |detect |possible |hemorrhage. |If |the |uterus |remains |boggy

|after |the |client |voids, |or |if |hemorrhage |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 |infection? |

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) |- |

When |collecting |data |on |a |neonate, |the |nurse |observes |a |vaguely |outlined |area |of |scalp
|edema. |Which |term |should |the |nurse |use |when |documenting |this |observation?

1. |Cephalhematoma

,2. |Petechiae
3. |Subdural |hematoma
4. |Caput |succedaneum |- |ANSWER |#4
RATIONALES: |Caput |succedaneum |refers |to |a |vaguely |outlined |area |of |scalp |edema |that
|crosses |the |suture |line |and |typically |clears |within |a |few |days |after |birth. |Cephalhematoma |is

|a |swelling |of |the |head |that |results |from |subcutaneous |bleeding |caused |by |pressure |exerted

|on |the |soft |tissues |during |delivery; |it's |characterized |by |sharply |demarcated |boundaries |that

|don't |cross |the |suture |lines. |Petechiae |are |minute, |circumscribed, |hemorrhagic |areas |of |the

|skin. |A |subdural |hematoma |is |a |collection |of |blood |between |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 |television |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 |frequently |than |it
|did |before. |

4. |The |client |searches |his |room |for |hidden |transmitters. |- |

Preschooler
For |a |child |who's |admitted |to |the |emergency |department |with |an |acute |asthma |attack,
|nursing |data |collection |is |most |likely |to |reveal: |

1. |apneic |periods. |
2. |expiratory |wheezing. |
3. |inspiratory |stridor. |
4. |absent |breath |sounds. |- |ANSWER |2
RATIONALES: |Expiratory |wheezing |is |common |during |an |acute |asthma |attack |and |results |from
|narrowing |of |the |airway |caused |by |edema. |Acute |asthma |rarely |causes |apneic |periods.

|Inspiratory |stridor |more |commonly |accompanies |croup. |Acute |asthma |is |more |likely |to |cause

|adventitious |breath |sounds |than |absent |breath |sounds; |however, |adventitious |sounds |are |an

|ominous |sign |because |the |client |is |unable |to |exchange |air.




Preschooler
The |physician |diagnoses |leukemia |in |a |child, |age |4, |who |complains |of |being |tired |and |sleeps
|most |of |the |day. |Which |nursing |diagnosis |reflects |the |nurse's |understanding |of |the

|pathophysiology |behind |leukemia? |

1. |Ineffective |airway |clearance |related |to |fatigue |
2. |Activity |intolerance |related |to |anemia |
3. |Imbalanced |nutrition: |More |than |body |requirements |related |to |lack |of |activity |
4. |Ineffective |cerebral |tissue |perfusion |related |to |central |nervous |system |infiltration |by
|leukemic |cells |- |Correct |Answer: |2

, RATIONALES: |A |child |with |leukemia |may |experience |anemia |from |bone |marrow |depression,
|such |as |from |chemotherapy |or |replacement |of |normal |bone |marrow |elements |by |immature

|white |blood |cells. |Anemia |results |in |fatigue, |lack |of |energy, |and |activity |intolerance. |The

|information |given |in |the |question |doesn't |support |the |other |diagnoses




Neurosensory |Disorders |
The |nurse |is |collecting |data |on |a |38-year-old |client |diagnosed |with |multiple |sclerosis. |Which
|of |the |following |symptoms |would |the |nurse |expect |to |find? |

1. |Vision |changes |
2. |Absent |deep |tendon |reflexes |
3. |Tremors |at |rest |
4. |Flaccid |muscles |- |Correct |Answer: |1 |
RATIONALES: |Vision |changes, |such |as |diplopia, |nystagmus, |and |blurred |vision, |are |symptoms
|of |multiple |sclerosis. |Deep |tendon |reflexes |may |be |increased |or |hyperactive |— |not |absent.

|Babinski's |sign |may |be |positive. |Tremors |at |rest |aren't |characteristic |of |multiple |sclerosis;

|however, |intentional |tremors, |or |those |occurring |with |purposeful |voluntary |movement, |are

|common |in |clients |with |multiple |sclerosis. |Affected |muscles |are |spastic, |rather |than |flaccid




Genitourinary |Disorders |
A |client |who |returned |from |a |cystoscopic |examination |complains |of |pain |while |attempting |to
|void. |Which |intervention |should |a |nurse |suggest |to |ease |the |client's |pain |while |attempting |to

|void? |

1. |Drink |plenty |of |fluids. |
2. |Pour |water |over |the |perineal |area. |
3. |Run |water |in |the |bathroom |sink. |
4. |Sit |in |a |warm |sitz |bath. |- |Correct |Answer: |4 |
RATIONALES: |The |best |intervention |is |for |the |client |to |sit |in |a |warm |sitz |bath |when |trying |to
|void. |Warm |water |relieves |pain |and |increases |circulation |to |the |perineal |area |and |relaxes |the

|muscles, |which |helps |start |the |voiding |process. |Drinking |plenty |of |fluids |will |hydrate |the

|kidneys |and |cause |the |client |to |make |more |urine. |Pouring |water |over |the |perineal |area |will

|stimulate |the |client |to |urinate. |Running |water |in |the |bathroom |sink |will |also |stimulate |the

|client |to |void |but |does |not |address |the |client's |pain.




The |Nursing |Process
A |client |has |a |nursing |diagnosis |of |Risk |for |injury |related |to |adverse |effects |of |potassium-
wasting |diuretics. |What |is |a |correctly |written |client |outcome |for |this |nursing |diagnosis? |
1. |"Before |discharge, |the |client |correctly |identifies |three |potassium-rich |food |sources." |
2. |"The |client |knows |the |importance |of |consuming |potassium-rich |foods |daily." |
3. |"Before |discharge, |the |client |knows |which |food |sources |are |high |in |potassium." |
4. |"The |client |understands |all |complications |of |the |disease |process." |- |Correct |Answer: |1 |
RATIONALES: |A |client |outcome |must |be |measurable, |objective, |concise, |realistic |for |the |client,
|and |attainable |through |nursing |management. |For |each |client |outcome, |the |nurse |should

|include |only |one |client |behavior, |should |express |that |behavior |in |terms |of |client |expectations,

|and |should |indicate |a |time |frame. |Knowing |the |importance |of |consuming |potassium-rich