Answers and Rationales for NCLEX-PN Practice Exam Part 8

View the NCLEX-PN Practice Test Part 8

1.      Answer D is correct. Protamine sulfate is given to counteract the effects of enoxaprin as well as heparin. Calcium gluconate is given to counteract the effects of magnesium sulfate; therefore, answer A is incorrect. Answer B is incorrect because aquamephyton is given to counteract the effects of sodium warfarin. Answer C is incorrect because methargine is given to increase uterine contractions following delivery.

2.      Answer A is correct. Participating in reality orientation is the most appropriate activity for the client who is confused. Answers B, C, and D are incorrect because they are not suitable activities for a client who is confused.

3.      Answer B is correct. The nurse should recommend acetaminophen for the child’s joint discomfort because it will have no effect on the bleeding time. Answers A, C, and D are all nonsteroidal anti-inflammatory medications that can prolong bleeding time; therefore, they are not suitable for the child with hemophilia.

4.      Answer D is correct. Applying a paste of baking soda and water soothes the itching and helps to dry the vesicles. The use of baby powder is not recommended for either children; therefore, answer A is incorrect. Answers B and C are incorrect because hydrogen peroxide and saline will not relieve the itching and will prevent the vesicles from crusting.

5.      Answer A is correct. The infant with hypospadias has altered patterns of urinary elimination caused by the location of the urinary meatus on the dorsum, or underside, of the penis. Answer B is incorrect because it refers to ureteral reflux. Answer C is incorrect because it refers to epispadias. Answer D is incorrect because it refers to exstrophy of the bladder.

6.      Answer D is correct. Zantac (ranitidine) should be administered in one dose at bedtime or with meals. Answers A, B, and C have incorrect times for dosing.

7.      Answer A is correct. Pain associated with angina is relieved by rest. Answer B is incorrect because it is not a true statement. Answer C is incorrect because pain associated with angina can be referred to the jaw, the left arm, and the back. Answer D is incorrect because pain from a myocardial infarction can be referred to areas other than the left arm.

8.      Answer A is correct. It would not be helpful to limit the fluid intake of a client during bowel retraining. Answers B, C, and D would help the client; therefore, they are incorrect answers.

9.      Answer B is correct. The client with Meniere’s disease should limit the intake of foods that contain sodium. Answers A, C, and D have no relationship to the symptoms of Meniere’s disease; therefore, they are incorrect.

10.  Answer A is correct. The nurse should pay close attention to swelling in the client with preeclampsia. Facial swelling indicates that the client’s condition is worsening and blood pressure will be increased. Answer B is not related to the question; therefore, it is incorrect. Answer C is incorrect because ankle edema is expected in pregnancy. Diminished reflexes are associated with the use of magnesium sulfate, which is the treatment of preeclampsia; therefore, answer D is incorrect.

11.  Answer D is correct. Verbalizing feelings of anger and sadness to a staff member is an appropriate therapeutic goal for the client with a risk of self-directed violence. Answers A and C place the client in an isolated situation to deal with her feelings alone; therefore, they are incorrect. Answer B is incorrect because it does not allow the client to ventilate her feelings.

12.  Answer C is correct. The nurse should remove any remaining ointment before applying the medication again. Answer A is incorrect because it interferes with absorption. Answer B does not apply to the question of how to administer the medication; therefore, it is incorrect. Answer D is incorrect because the medication’s action is more immediate.

13.  Answer D is correct. Telling the client what happened and where he is helps with reorientation. Answer A does not explain what happened to the client; therefore, it is incorrect. Answer B is not helpful because the client regaining consciousness will not know where he is; therefore, the answer is incorrect. The nurse should not offer false reassurances, such as "everything will be alright"; therefore, answer C is incorrect.

14.  Answer B is correct. Following a generalized seizure, the client frequently experiences drowsiness and postictal sleep. Answer A is incorrect because the client is able to move the extremities. Answer C is incorrect because the client can remember events before the seizure. Answer D is incorrect because the blood pressure is elevated.

15.  Answer A is correct. The client with oxylate renal calculi should avoid sources of oxylate, which include strawberries, rhubarb, and spinach. Answers B, C, and D are incorrect because they are not sources of oxylate.

16.  Answer D is correct. The child with Legg-Calve Perthes disease should be prevented from bearing weight on the affected extremity until revascularization has occurred. Answer A is incorrect because it does not relate to the condition. Answers B and C are incorrect choices because the condition does not involve the muscles or the joints.

17.  Answer B is correct. The child with Hirschsprung’s disease will have a scaphoid or hollowed abdomen. Answers A, C, and D do not apply to the condition; therefore, they are incorrect.

18.  Answer B is correct. Iron supplements should be taken with a source of vitamin C to promote absorption. Answer A is incorrect because iron should not be taken with milk. Answer C is incorrect because high-fiber sources prevent the absorption of iron. Answer D is an inaccurate statement; therefore, it is incorrect.

19.  Answer A is correct. The client does not need to drastically reduce her caloric intake during pregnancy. Doing so would not provide adequate nourishment for proper development of the fetus. Answers B, C, and D indicate that the client understands the nurse’s dietary teaching regarding obesity and hypertension; therefore, they are incorrect.

20.  Answer B is correct. Confusion, disorientation, behavioral changes, and alterations in judgment are early signs of dementia. Answers A, C, and D do not relate to the question; therefore, they are incorrect.

21.  Answer C is correct. In the left occipital posterior position, the heart sounds will be heard loudest through the fetal back. Answers A, B, and D are incorrect locations.

22.  Answer B is correct. Benzodiazepines such as clonazepam and lorazepam are given to the client withdrawing from alcohol. Answer A is incorrect because methodone is given to the client withdrawing from opiates. Answer C is incorrect because naloxone is an antidote for narcotic overdose. Answer D is incorrect because disufiram is used in aversive therapy for alcohol addiction.

23.  Answer C is correct. The client’s breakfast should be served within 30 minutes to coincide with the onset of the client’s regular insulin.

24.  Answer C is correct. The nurse should administer .7mL of the medication. Answers A, B, and D are incorrect because the dosage is incorrect.

25.  Answer A is correct. Tetracycline is contraindicated for use in infants and young children because it stains the teeth and arrests bone development. Answers B, C, and D are incorrect because they can be used to treat infections in infants and children.