NCLEX Comprehensive Review Answers and Rationale

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3.      The correct answer is B: thrombus formation Thrombus formation in the coronary arteries is a potential problem in the initial 24 hours after a cardiac catheterization. A falling BP occurs along with hemorrhage of the insertion site which is associated with the first 12 hours after the procedure.

4.      The correct answer is C: Manage pain The immediate goal of therapy is to alleviate the client’s pain.

5.      The correct answer is D: Yearly weight gain of about 5.5 pounds per year School age children gain about 5.5 pounds each year and increase about 2 inches in height.

6.      The correct answer is A: go get a blood pressure check within the next 48 to 72 hours The blood pressure reading is moderately high with the need to have it rechecked in a few days. The client states it is ‘usually much lower.’ Thus a concern exists for complications such as stroke. However immediate check by the provider of care is not warranted. Waiting 2 months or a week for follow-up is too long.

7.      The correct answer is A: A middle aged client with a history of being ventilator dependent for over 7 years and admitted with bacterial pneumonia five days ago The best candidate for discharge is one who has had a chronic condition and is most familiar with their care. This client in option A is most likely stable and could continue medication therapy at home.

8.      The correct answer is A: Should be taken in the morning Thyroid supplement should be taken in the morning to minimize the side effects of insomnia

9.      The correct answer is D: Notify the health care provider of the child”s status These findings suggest a medical emergency and may be due to epiglottises. Any child with an acute onset of an inflammatory response in the mouth and throat should receive immediate attention in a facility equipped to perform intubation or a tracheostomy in the event of further or complete obstruction.

10.  The correct answer is C: Bed wetting In children, fatigue and bed wetting are the chief complaints that prompt parents to take their child for evaluation. Bed wetting in a school age child is readily detected by the parents.

11.  The correct answer is B: Chlamydia Chlamydial infections are one of the most frequent causes of salpingitis or pelvic inflammatory disease.

12.  The correct answer is C: An adolescent who has been on pain medications for terminal cancer with an initial assessment finding of pinpoint pupils and a relaxed respiratory rate of 10 Nurses who are floated to other units should be assigned to a client who has minimal anticipated immediate complications of their problem. The client in option C exhibits opoid toxicity with the pinpoint pupils and has the least risk of complications to occur in the near future.

13.  The correct answer is C: Avoiding very heavy meals eating large, heavy meals can pull blood away from the heart for digestion and is dangerous for the client with coronary artery disease.

14.  The correct answer is C: The level of drug is 100 ml at 8 AM and is 80 ml at noon The minimal dose of 10 ml per hour which would be 40 ml given in a 4 hour period. Only 60 ml should be left at noon. The pump is not functioning when more than expected medicine is left in the container.

15.  The correct answer is B: Spinal column manipulation The theory underlying chiropractic is that interference with transmission of mental impulses between the brain and body organs produces diseases. Such interference is caused by misalignment of the vertebrae. Manipulation reduces the subluxation.

16.  The correct answer is A: Decrease in level of consciousness A further decrease in the level of consciousness would be indicative of a further progression of the CVA.

17.  The correct answer is C: Moist, productive cough Option c is a later sign. Noisy respirations and a dry non-productive cough are commonly the first of the respiratory signs to appear in a newly diagnosed client with cystic fibrosis (CF). The other options are the earliest findings. CF is an inherited (genetic) condition affecting the cells that produce mucus, sweat, saliva and digestive juices. Normally, these secretions are thin and slippery, but in CF, a defective gene causes the secretions to become thick and sticky. Instead of acting as a lubricant, the secretions plug up tubes, ducts and passageways, especially in the pancreas and lungs. Respiratory failure is the most dangerous consequence of CF.

18.  The correct answer is B: Send him to the emergency room for evaluation This client requires immediate evaluation. A delay in treatment could result in further deterioration and harm. Home care nurses must prioritize interventions based on assessment findings that are in the client’s best interest.

19.  The correct answer is D: No special orders are necessary for this examination No special preparation is necessary for this examination.

20.  The correct answer is B: “When you can climb 2 flights of stairs without problems, it is generally safe.” There is a risk of cardiac rupture at the point of the myocardial infarction for about 6 weeks. Scar tissue should form about that time. Waiting until the client can tolerate climbing stairs is the usual advice given by health care providers.

21.  The correct answer is B: A teenager who got singed a singed beard while camping This client is in the greatest danger with a potential of respiratory distress, Any client with singed facial hair has been exposed to heat or fire in close range that could have caused damage to the interior of the lung. Note that the interior lining of the lung has no nerve fibers so the client will not be aware of swelling.

22.  The correct answer is C: “I understand the need to use those new skills.” Erikson describes the stage of the toddler as being the time when there is normally an increase in autonomy. The child needs to use motor skills to explore the environment.

23.  The correct answer is A: Verify correct placement of the tube Proper placement of the tube prevents aspiration.

24.  The correct answer is C: Tall peaked T waves A tall peaked T wave is a sign of hyperkalemia. The health care provider should be notified regarding discontinuing the medication.

25.  The correct answer is A: All striated muscles Rhabdomyosarcoma is the most common children”s soft tissue sarcoma. It originates in striated (skeletal) muscles and can be found anywhere in the body. The clue is in the middle of the word and is “myo” which typically means muscle.

26.  The correct answer is D: Restore yin and yang For followers of Chinese medicine, health is maintained through balance between the forces of yin and yang.

27.  The correct answer is C: Force fluids and reassess blood pressure Postural hypotension, a decrease in systolic blood pressure of more than 15 mm Hg and an increase in heart rate of more than 15 percent usually accompanied by dizziness indicates volume depletion, inadequate vasoconstrictor mechanisms, and autonomic insufficiency.

28.  The correct answer is B: Left heart function The Swan-Ganz catheter is placed in the pulmonary artery to obtain information about the left side of the heart. The pressure readings are inferred from pressure measurements obtained on the right side of the circulation. Right-sided heart function is assessed through the evaluation of the central venous pressures (CVP).

29.  The correct answer is C: Establish an airway Establishing an airway is always the primary objective in a cardiopulmonary arrest.

30.  The correct answer is A: Blood pressure 94/60 Both medications decrease the heart rate. Metoprolol affects blood pressure. Therefore, the heart rate and blood pressure must be within normal range (HR 60-100; systolic B/P over 100) in order to safely administer both medications.

31.  The correct answer is C: Inspiratory grunt Inspiratory grunting is abnormal and may be a sign of respiratory distress in this infant.

32.  The correct answer is D: Progressive placental insufficiency The placenta functions less efficiently as pregnancy continues beyond 42 weeks. Immediate and long term effects may be related to hypoxia.

33.  The correct answer is B: “I just can”t ”catch my breath” over the past few minutes and I think I am in grave danger.” The nurse would be concerned about all of these comments. However the most life threatening is option B. Clients who have had hip or knee surgery are at greatest risk for development of post operative pulmonary embolism. Sudden dyspnea and tachycardia are classic findings of pulmonary embolism. Muscle spasms do not require immediate attention. Option C may indicate a urinary tract infection. And option D requires further investigation and is not life threatening.

34.  The correct answer is D: Decreased appetite Lasix causes a loss of potassium if a supplement is not taken. Signs and symptoms of hypokalemia include anorexia, fatigue, nausea, decreased GI motility, muscle weakness, dysrhythmias.

35.  The correct answer is C: Gravida 3 para 1 Gravida is the number of pregnancies and Parity is the number of pregnancies that reach viability (not the number of fetuses). Thus, for this woman, she is now pregnant, had 2 prior pregnancies, and 1 viable birth (twins).

36.  The correct answer is B: Improve the client”s nutrition status The goal of clinical management in a client with venous stasis ulcers is to promote healing. This only can be accomplished with proper nutrition. The other answers are correct, but without proper nutrition, the other interventions would be of little help.

37.  The correct answer is D: Have the client empty bladder The first step in the process is to have the client void prior to administering the pre-operative medication. The other actions follow this initial step in this sequence: 4 3 1 2

38.  The correct answer is A: Specific feedback is given as close to the event as possible Feedback is most useful when given immediately. Positive behavior is strengthened through immediate feedback, and it is easier to modify problem behaviors if the standards are clearly understood.

39.  The correct answer is B: Lead to dehydration The client must take in adequate fluids before and during exercise periods.

40.  The correct answer is C: We have safety bars installed in the bathroom and have 24 hour alarms on the doors. Ensuring safety of the client with increasing memory loss is a priority of home care. Note all options are correct statements. However, safety is most important to reinforce.