Answers and Rationales for NCLEX-PN Practice Exam Part 5

View the NCLEX-PN Practice Test Part 5

1.      Answer C is correct. Changes in breath sounds are the best indication of the need for suctioning in the client with ineffective airway clearance. Answers A, B, and D are incorrect because they can be altered by other conditions.

2.      Answer D is correct. An adverse reaction to Myambutol is change in visual acuity or color vision. Answer A is incorrect because it does not relate to the medication. Answer C is incorrect because it is an adverse reaction to Streptomycin. Answer C is incorrect because it is a side effect of Rifampin.

3.      Answer D is correct. Insufficient erythropoietin production is the primary cause of anemia in the client with chronic renal failure. Answers A, B, and C do not relate to the anemia seen in the client with chronic renal failure; therefore, they are incorrect.

4.      Answer C is correct. The contrast media used during an intravenous pyelogram contains iodine, which can result in an anaphylactic reaction. Answers A, B, and D do not relate specifically to the test; therefore, they are incorrect.

5.      Answer D is correct. Aspirin prevents the platelets from clumping together to prevent clots. Answer A is incorrect because the low-dose aspirin will not prevent headaches. Answers B and C are untrue statements; therefore, they are incorrect.

6.      Answer C is correct. The usual course of treatment requires that medication be given for 18 months to 2 years. Answers A and D are incorrect because the treatment time is too brief. Answer B is incorrect because the medication is not needed for life.

7.      Answer D is correct. At 4 months of age, the infant can roll over, which makes it vulnerable to falls from dressing tables or beds without rails. Answer A is incorrect because it does not prove a threat to safety. Answers B and C are incorrect because the 4-month-old is not capable of crawling or standing.

8.      Answer C is correct. Adverse side effects of Dilantin include agranulocytosis and aplastic anemia; therefore, the client will need frequent CBCs. Answer A is incorrect because the medication does not cause dental staining. Answer B is incorrect because the medication does not interfere with the metabolism of carbohydrates. Answer D is incorrect because the medication does not cause drowsiness.

9.      Answer A is correct. The infant with hypospadias should not be circumcised because the foreskin is used in reconstruction. Answer B and C are incorrect because reconstruction is done between 16 and 18 months of age, before toilet training. Answer D is incorrect because the infant with hypospadias should not be circumcised.

10.  Answer C is correct. Coconut oil is high in saturated fat and is not appropriate for the client on a low-cholesterol diet. Answers A, B, and D are incorrect because they are suggested for the client with elevated cholesterol levels.

11.  Answer B is correct. In stage III of Alzheimer’s disease, the client develops agnosia, or failure to recognize familiar objects. Answer A is incorrect because it appears in stage I. Answer C is incorrect because it appears in stage II. Answer D is incorrect because it appears in stage IV.

12.  Answer D is correct. The client taking steroid medication should receive an annual influenza vaccine. Answer A is incorrect because the medication should be taken with food. Answer B is incorrect because increased appetite and weight gain are expected side effects of the medication. Answer C is incorrect because wearing sunglasses will not prevent cataracts.

13.  Answer A is correct. The client with an above-the-knee amputation should be placed prone 15–30 minutes twice a day to prevent contractures. Answers B and D are incorrect because elevating the extremity after the first 24 hours will promote the development of contractures. Use of a trochanter roll will prevent rotation of the extremity but will not prevent contracture; therefore, answer D is incorrect.

14.  Answer D is correct. All 20 primary, or deciduous, teeth should be present by age 30 months. Answers A, B, and C are incorrect because the ages are wrong.

15.  Answer C is correct. The radioactive implant should be picked up with tongs and returned to the lead-lined container. Answer A is incorrect because radioactive materials are placed in lead-lined containers, not plastic ones, and are returned to the radiation department, not the lab. Answer B is incorrect because the client should not touch the implant or try to reinsert it. Answer D is incorrect because the implant should not be placed in the commode for disposal.

16.  Answer A is correct. Following a laparoscopic cholecystectomy, the client should avoid a tub bath for 48 hours. Answer B is incorrect because the stools should not be clay colored. Answer C is incorrect because pain is usually located in the shoulders. Answer D is incorrect because the client should not resume a regular diet until clear liquids have been tolerated.

17.  Answer B is correct. The client recovering from mononucleosis should avoid contact sports and other activities that could result in injury or rupture of the spleen. Answer A is incorrect because the client does not need additional fluids. Hypoglycemia is not associated with mononucleosis; therefore, answer C is incorrect. Answer D is incorrect because antibiotics are not usually indicated in the treatment of mononucleosis.

18.  Answer B is correct. Pancreatic enzyme replacement is given with each meal and each snack. Answers A, C, and D do not specify a relationship to meals; therefore, they are incorrect.

19.  Answer A is correct. Meat, eggs, and dairy products are foods high in vitamin B12. Answer B is incorrect because peanut butter, raisins, and molasses are sources rich in iron. Answer C is incorrect because broccoli, cauliflower, and cabbage are sources rich in vitamin K. Answer D is incorrect because shrimp, legumes, and bran cereals are high in magnesium.

20.  Answer A is correct. The client’s aerobic workout should be 20–30 minutes long three times a week. Answers B, C, and D exceed the recommended time for the client beginning an aerobic program; therefore, they are incorrect.

21.  Answer A is correct. A total mastectomy involves removal of the entire breast and some or all of the axillary lymph nodes. Following surgery, the client’s right arm should be elevated on pillows, to facilitate lymph drainage. Answers B, C, and D are incorrect because they would not help facilitate lymph drainage and would create increased edema in the affected extremity.

22.  Answer D is correct. Absence seizures, formerly known as petit mal seizures, are characterized by a brief lapse in consciousness accompanied by rapid eye blinking, lip smacking, and minor myoclonus of the upper extremities. Answer A refers to myoclonic seizure; therefore, it is incorrect. Answer B refers to tonic clonic, formerly known as grand mal, seizures; therefore, it is incorrect. Answer C refers to atonic seizures; therefore, it is incorrect.

23.  Answer A is correct. A side effect of antipsychotic medication is the development of Parkinsonian symptoms. Answers B and C are incorrect because they are used to reverse Parkinsonian symptoms in the client taking antipsychotic medication. Answer D is incorrect because the medication is an anticonvulsant used to stabilize mood. Parkinsonian symptoms are not associated with anticonvulsant medication.

24.  Answer B is correct. Exercises that provide light passive resistance are best for the child with rheumatoid arthritis. Answers A and C require movement of the hands and fingers that might be too painful for the child with juvenile rheumatoid arthritis; therefore, they are incorrect. Answer D is incorrect because it requires the use of larger joints affected by the disease.

25.  Answer B is correct. The client’s diabetes is well under control. Answer A is incorrect because it will lead to elevated glycosylated hemoglobin. Answer C is incorrect because the diet and insulin dose are appropriate for the client. Answer D is incorrect because the desired range for glycosylated hemoglobin in the adult client is 2.5%–5.9%