NCLEX PN Examination (Example and Answer) 65th Edition
NCLEX PN Examination (Example and Answer) 65th Edition
1. A prenatal client has acquired the sexually transmitted virus condyloma acuminatum (human papilloma virus). When assisting in planning care, which of the following treatments would the nurse consider to be safe for this maternity client?
A. Laser therapy
B. Use of cytotoxic agents
C. Treatment with interferon
D. All treatment should be avoided
Answer: A. Laser therapy
Rationale: Laser therapy is the most effective method of treatment for this disorder that is considered safe for pregnancy. Medications for the disease are considered toxic to the fetus. The primary neonatal effect of the virus is respiratory or laryngeal papillomatosis. The exact route of perinatal transmission is unknown.
Teat-Taking Strategy: Use the process of elimination. Eliminate options that contain absolute words such as “all” in option D. Medication use during pregnancy is very limited and should not be the first treatment measure; therefore eliminate options 2 and C. Review treatment modalities related to condyloma acuminatum if you had difficulty with this question.
Level of Cognitive Ability: Analysis
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Planning
Content Area: Maternity/Antepartum
References: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed.). St. Louis: Elsevier, pp. 662, 790.
Murray, S., McKinney, E., & Gorrie, T. (2002). Foundations of maternal-newborn nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 958.
2. A client with tuberculosis is being started on antituberculosis therapy with isoniazid (INH). The nurse reviews the client’s health care record to be sure that which of the following baseline studies have been completed before giving the client the first dose?
A. Coagulation times
B. Electrolytes
C. Serum creatinine
D. Liver enzymes
Answer: D. Liver enzymes
Rationale: Isoniazid therapy can cause an elevation of hepatic enzymes and hepatitis. Therefore liver enzymes are monitored when therapy is initiated and during the first 3 months of therapy. They may be monitored longer in the client who is over age 50 or abuses alcohol. Options 1, 2, and 3 are not specifically related to the administration of this medication.
Test-Taking Strategy: Focus on the name of the medication. Recalling that this medication can be toxic to the liver will direct you to the correct option. Review this medication if you had difficulty with this question.
Level of Cognitive Ability: Analysis
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Adult Health/Respiratory
Reference: Lehne, R. (2004). Pharmacology for nursing care (5th ed.). Philadelphia: W.B. Saunders, p. 944.
3. A nurse is monitoring the respiratory status of the client who has suffered a fractured rib. The nurse monitors the client and understands that which manifestation is unrelated to the rib fracture?
A. Pain, especially with inspiration
B. Slow, deep respirations
C. Splinting or guarding the chest
D. Bruising over the fracture area
Answer: B. Slow, deep respirations
Rationale: Rib fractures are a common injury, especially in the older client, and result from a blunt injury or a fall. Typical signs and symptoms include pain and tenderness that is localized at the fracture site and is exacerbated by inspiration and palpation, shallow respirations, splinting or guarding the chest protectively to minimize chest movement, and possible bruising at the fracture site.
Test-Taking Strategy: Use the process of elimination and note the key word unrelated. This word indicates a false response question, and you need to select the incorrect manifestation. Knowing that fractured ribs can cause pain and bruising helps you to eliminate options 1 and 4 first. To select between options 2 and 3, recalling that pain causes shallow, guarded respirations helps you to choose option 2 as the unrelated finding. Review the clinical manifestations in rib fractures if you had difficulty with this question.
Level of Cognitive Ability: Comprehension
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Data Collection
Content Area: Adult Health/Respiratory
Reference: Linton, A. & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 487.
4. A nurse is admitting a client to the nursing unit who is suspected of having tuberculosis. The nurse plans to admit the client to a room that has:
A. Ultraviolet light and three air exchanges per hour
B. Ten air exchanges per hour and venting to the outside
C. Venting to the outside and ultraviolet light
D. Venting to the outside, six air exchanges per hour, and ultraviolet light
Answer: D. Venting to the outside, six air exchanges per hour, and ultraviolet light
Rationale: The client is admitted to a private room that has at least six air exchanges per hour, and which has negative pressure in relation to surrounding areas. The room should be vented to the outside and should have ultraviolet lights installed.
Test-Taking Strategy: Begin to answer this question by recalling the specific requirements of physical facilities that are used in the care of clients with TB. Knowing that the air must vent to the outside helps to eliminate option A. Knowing that ultraviolet light is useful in killing these organisms helps you to eliminate option B. To select between the last two options, it is necessary to know that there must be an airflow system that allows for at least six air exchanges per hour. Review care to the client hospitalized with TB 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: Adult Health/Respiratory
Reference: Christensen, B. & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 375.
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