Example NCLEX Question with Rationale 27th Edition

Example NCLEX Question with Rationale 27th Edition (Child Health and Pharmacology)

1. A nursing instructor asks a nursing student about the use of the bacille Calmette-Guérin vaccine (BCG). The nursing student responds correctly knowing that the BCG vaccine is used for:
A. Children with a positive Mantoux test
B. Children with both a positive Mantoux test and a positive chest x-ray
C. All children to prevent tuberculosis (TB)
D. Asymptomatic human immunodeficiency virus (HIV) infected children who are at increased risk for developing TB

Answer: D. Asymptomatic human immunodeficiency virus (HIV) infected children who are at increased risk for developing TB

Rationale: The BCG vaccine is used mainly for children with a negative chest x-ray and skin test results who have had repeated exposures to TB, and for asymptomatic HIV-infected children who are at increased risk for developing TB.

Test-Taking Strategy: Use the process of elimination. Recalling that BCG is a preventative vaccine will assist in eliminating options 1 and B. From the remaining options, eliminate option 3 because of the absolute word “all” in this option. Review the indications for the use of this vaccine if you had difficulty with this question.

Level of Cognitive Ability: Application
Client Needs: Health Promotion and Maintenance
Integrated Process: Teaching/Learning
Content Area: Child Health
Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed.). St. Louis: Elsevier, p. 1246.

2. A client with Parkinson’s disease has been prescribed benztropine (Cogentin). The nurse monitors for which gastrointestinal (GI) side effect of this medication?

A. Diarrhea
B. Dry mouth
C. Increased appetite
D. Hyperactive bowel sounds

Answer: B. Dry mouth

Rationale: Common GI side effects of benztropine therapy include constipation and dry mouth. Other GI side effects include nausea and ileus. These effects are the result of the anticholinergic properties of the medication.

Test-Taking Strategy: Use the process of elimination. Eliminate options 1 and 4 first because they are similar. From the remaining options, recalling that the medication is an anticholinergic would help you to choose dry mouth as the side effect. Review this medication if you had difficulty with this question.

Level of Cognitive Ability: Application
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Data Collection
Content Area: Pharmacology
Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 116.

3. A client with a history of simple partial seizures is taking clorazepate (Tranxene) and asks the nurse if there is a risk of addiction. The nurse’s response is based on the understanding that clorazepate:

A. Is not habit forming either physically or psychologically
B. Leads to physical and psychological dependence with prolonged high-dose therapy
C. Leads to physical tolerance, but only after 10 or more years of therapy
D. Can result in psychological dependence only, due to the nature of the medication

Answer: 2

Rationale: Clorazepate is classified as an anticonvulsant, antianxiety agent, and sedative/hypnotic (benzodiazepine). One of the nursing implications of clorazepate therapy is that the medication can lead to physical or psychological dependence when there is prolonged therapy at high doses. For this reason, the amount of medication that is readily available to the client at any one time is restricted. Options 1, 3, and 4 are incorrect.

Test-Taking Strategy: Use the process of elimination. Eliminate options 3 and 4 first because of the absolute word “only” in these options. From the remaining options, recalling that the medication is a benzodiazepine leads you to conclude that this medication can lead to physical as well as psychological dependence. Review this medication if you had difficulty with this question.

Level of Cognitive Ability: Application
Client Needs: Psychosocial Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Pharmacology
Reference: Skidmore-Roth, L. (2005). Mosby’s drug guide for nurses (6th ed.). St. Louis: Mosby, p. 213.

4. A client who was started on anticonvulsant therapy with clonazepam (Klonopin) tells the nurse of increasing clumsiness and unsteadiness since starting the medication. The client is visibly upset by these manifestations and asks the nurse what to do. The nurse’s response is based on the understanding that these symptoms:

A. Are most severe during initial therapy, and decrease or disappear with long-term use
B. Indicate that the client is experiencing a severe untoward reaction to the medication
C. Are probably the result of an interaction with another medication
D. Usually occur if the client takes the medication with food

Answer: A. Are most severe during initial therapy, and decrease or disappear with long-term use

Rationale: Drowsiness, unsteadiness, and clumsiness are expected effects of the medication during early therapy. They are dose related, and usually diminish or disappear altogether with continued use of the medication. It does not indicate that a severe side effect is occurring. It is also unrelated to interaction with another medication. The client is encouraged to take this medication with food to minimize gastrointestinal upset.

Test-Taking Strategy: Use the process of elimination. Eliminate options 2 and 3 first because they are similar and because of the word “severe” in option B. From the remaining options, recalling that drowsiness, unsteadiness, and clumsiness are expected effects of the medication during early therapy will direct you to option A. Review this medication if you had difficulty with this question.

Level of Cognitive Ability: Analysis
Client Needs: Psychosocial Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Pharmacology
Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 245.

5. A hospitalized client is having the dosage of clonazepam (Klonopin) adjusted. The nurse should plan to:

A. Monitor blood glucose levels
B. Institute seizure precautions
C. Weigh the client daily
D. Observe for areas of ecchymosis

Answer: B. Institute seizure precautions

Rationale: Clonazepam is a benzodiazepine that is used as an anticonvulsant. During initial therapy and during periods of dosage adjustment, the nurse should initiate seizure precautions for the client. Options 1, 3, and 4 are not associated with the use of this medication.

Test-Taking Strategy: Focus on the name of the medication. Recalling that clonazepam is a benzodiazepine that is used as an anticonvulsant will direct you to option B. Review this medication if you had difficulty with this question.

Level of Cognitive Ability: Application
Client Needs: Safe, Effective Care Environment
Integrated Process: Nursing Process/Planning
Content Area: Pharmacology
Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 245.

Source : NCLEX example quiz and answer

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