(ANSWERS & RATIONALE) NCLEX Comprehensive Exam Part 2

NCLEX Comprehensive Exam Part 2 Questions

1. ANSWER D. Symptoms of pregnancy-induced hypertension (PIH), such as hypertension and facial swelling, before 24 weeks’ gestation and a fundal height larger than expected are suggestive of gestational trophoblastic disease or hydatidiform mole. This condition occurs when the trophoblasts develop abnormally. Ultrasound can confirm the condition. Medical management includes evacuation of the mole and follow-up to detect any malignant changes. Painless vaginal bleeding is suggestive of placenta previa. Fetal anemia is often caused by Rh sensitization. Clients with multifetal pregnancies may exhibit larger fundal heights than expected, but they usually do not have a brownish discharge or symptoms of PIH at this stage of gestation.

2. ANSWER A. Saying, “When you interrupt others, they leave the area,” is most helpful because it serves to increase the client’s awareness of how others view him by giving him specific feedback about his behavior. The other statements are punitive and authoritative, possibly threatening to the client, and likely to increase defensiveness, decrease self-worth, and increase feelings of guilt.

3. ANSWER D. The trough serum level should be drawn just before the administration of the next intravenous dose of gentamicin sulfate (Garamycin).

4. ANSWER A. Health-promoting strategies for clients with a history of cardiovascular disease require knowledge in three areas: diet, exercise, and medication. Pain management and management of social activities are not usually features of health promotion activities for these clients.

5. ANSWER C. The child is exhibiting signs and symptoms of possible epiglottitis. As a result the child is at high risk for laryngospasm and airway occlusion. Therefore, the nurse should have a tracheostomy tube and setup readily available should the child experience an airway occlusion. Although acetaminophen is an antipyretic, the dosage of 600 mg to be administered rectally is too high. A typical 4-year-old weighs approximately 40 pounds. The recommended dose is 125 mg. When any type of respiratory illness, and especially epiglottitis, is suspected, putting any object, including a tongue depressor for inspection or a cotton-tipped applicator to obtain a throat culture, in the back of the mouth or throat or having the child open the mouth is inappropriate because doing so may predispose the child to laryngospasm or occlusion of the airway by a swollen epiglottis.

6. ANSWER C. The client is exhibiting the side effects associated with lithium therapy that are temporary. Therefore, the nurse would continue the lithium and explain to the client that he or she is experiencing temporary side effects of lithium that will subside. Common side effects of lithium are nausea, dry mouth, diarrhea, thirst, mild hand tremor, weight gain, bloating, insomnia, and lightheadedness. Immediately notifying the physician about these common side effects is not necessary.

7. ANSWER A. Thyroid replacement is a lifelong maintenance therapy. The medication is usually given as one dose in the morning. It cannot be tapered or discontinued, because the client needs thyroid supplementation to maintain health. The medication cannot be discontinued after the TSH level is normal; the dose will be maintained at the level that normalizes the TSH concentration.

8. ANSWER D. A client who is beginning training for a tennis team would most likely require an adjustment in lithium dosage because excessive sweating can increase the serum lithium level, possibly leading to toxicity. Adjustments in lithium dosage would also be necessary when other medications have been added, when an illness with high fever occurs, and when a new diet begins.

9. ANSWER C. The most appropriate response is to continue all treatments and attempt to stabilize the client using fluid replacement without administering blood or blood products. It is imperative that the health care team respect the client’s religious belief and wishes, even if they are not those of the health care team. Discontinuing all measures is not an option. The health care team should continue to provide the best care possible and does not need to notify the attorney.

10. ANSWER B. Cystic fibrosis is the most common inherited disease in children. It is inherited as an autosomal recessive trait, meaning that the child inherits the defective gene from both parents. The chances are one in four for each of this couple’s pregnancies.

11. ANSWER C. Nitroglycerin in all dosage forms (sublingual, transdermal, or intravenous) should be shielded from light to prevent deterioration. Clients should be instructed to keep the nitroglycerin in the dark container that is supplied by the pharmacy, and it should not be removed or placed in any other container.

12. ANSWER A, B, and D. Sinus bradycardia has the following characteristics: 1) P wave is normal and consistent in shape, occurring in front of every QRS complex; 2) a ventricular and atrial rate less than 60 bpm; and 3) a PR interval that is between 0.12 to 0.20 seconds. An atrial rate of 120 bpm indicates tachycardia. ST segment elevation may indicate a myocardial infarction.

13. ANSWER C. Valproic acid (Depakene) causes sedation as well as nausea, vomiting, and indigestion. Sedation is important because the client needs to be cautioned about driving or operating machinery that could be dangerous while feeling sedated from the medication. Depakene does not cause an increase in urination, slowed thinking, or weight loss. However, some clients may experience weight gain.

14. ANSWER A. These effects and others when seen after birth are known as a cluster of symptoms called fetal alcohol syndrome. Vitamin B6 and vitamin A deficiency can affect growth and development but not with these specific effects. Folic acid deficiency contributes to neural tube defects.

15. ANSWER D. NSAIDs are irritating to the gastric mucosa and should be taken with food. NSAIDs are usually taken once or twice daily. Joint exercise is not related to the drug administration. Antacids may interfere with the absorption of the drug.

16. ANSWER B. The client who drinks alcohol while taking disulfiram (Antabuse) will experience sweating, flushing of the neck and face, tachycardia, hypotension, a throbbing headache, nausea and vomiting, palpitations, dyspnea, tremor, and/or weakness.

17. ANSWER C. Holding the gauze pledget against an intramuscular injection site while removing the needle from the muscle avoids the discomfort of the needle pulling on the skin.

18. ANSWER C. Physical activity is gradually increased after a myocardial infarction while the client is still hospitalized and through a period of rehabilitation. The client is progressing too rapidly if activity significantly changes respirations, causing dyspnea, chest pain, a rapid heartbeat, or fatigue. When any of these symptoms appears, the client should reduce activity and progress more slowly. Edema suggests a circulatory problem that must be addressed but doesn’t necessarily indicate overexertion. Cyanosis indicates reduced oxygen-carrying capacity of red blood cells and indicates a severe pathology. It is not appropriate to use cyanosis as an indicator for overexertion. Weight loss is indicative of several factors but not overexertion.

19. ANSWER C. When a client talks about not having a problem with alcohol, the nurse needs to point out how alcohol has gotten the client into trouble. Concrete, factual information is helpful in decreasing the client’s denial that alcohol is a problem. The other approaches allow the client to use defense mechanisms, such as rationalization, projection, and minimization, to explain her actions. Therefore, these approaches are not helpful.

20. ANSWER C. Medicaid is state funded, with matching federal funds, and provides medical assistance for low-income persons without health insurance. The program for older adults is Medicare.