NCLEX Practice Test With Answers and Rationale 89th Edition
NCLEX Practice Test With Answers and Rationale 89th Edition
1. A nurse is assisting in preparing a plan of care for a child who will be returning from surgery following the application of a hip spica cast. Which of the following would be the priority in the plan of care for this child upon return from the procedure?
A. Elevate the head of the bed
B. Turn the child on the right side
C. Check circulation
D. Abduct the hips using pillows
Answer: C. Check circulation
Rationale: During the first few hours after a cast is applied, the primary concern is swelling that may cause the cast to produce a tourniquet-like effect and restrict circulation. Therefore circulatory assessment is a priority. Elevating the head of the bed of a child in a hip spica would cause discomfort. Using pillows to abduct the hips is not necessary because a hip spica immobilizes the hip and the knee. Turning the child side to side at least every 2 hours is important because it allows the body cast to dry evenly and prevents complications related to immobility; however, it is not as important as checking circulation.
Test-Taking Strategy: Use the process of elimination and note the key word priority. Use the ABCs, airway, breathing, and circulation, to answer this question. Option 3 addresses circulatory status. Review care to the child following the application of a hip spica cast if you had difficulty with this question.
Level of Cognitive Ability: Application
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Planning
Content Area: Child Health
Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child
nursing (2nd ed.). St. Louis: Elsevier, p. 1409.
2. A nurse is caring for a client who has tuberculosis (TB). Rifampin (Rifadin), 600 mg by mouth daily, is prescribed for the client. The nurse provides instructions to the client regarding the administration of this medication. Which of the following statements by the client indicates an understanding of the instructions?
A. “I need to limit alcohol intake.”
B. “I will need to take the medication for months.”
C. “I need to take the medication with meals.”
D. “I need to call the physician if the color of my urine turns red-orange.”
Answer: B. “I will need to take the medication for months.”
Rationale: The client needs to avoid alcohol while taking this medication. The medication should be taken on an empty stomach with 8 oz of water 1 hour before or 2 hours after meals. The client should be told that urine, feces, sweat, and tears may turn red-orange. The client should also be instructed that doses should not be skipped, and the medication needs to be taken as prescribed for the full length of therapy, which may range from 6 to 9 months up to 1 year. The nurse should note any elevation of the alkaline phosphatase, which would indicate possible hepatotoxicity.
Test-Taking Strategy: Use the process of elimination. Eliminate option 1 first, using basic principles related to medication therapy. Knowledge that medication therapy for TB is prescribed for months to a year or more will assist you in eliminating options 3 and 4 and direct you to option B. Review pharmacological therapy for TB if you had difficulty with this question.
Level of Cognitive Ability: Analysis
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Evaluation
Content Area: Pharmacology
References: Lehne, R. (2004). Pharmacology for nursing care (5th ed.). Philadelphia: W.B. Saunders, p. 951.
McKenry, L., & Salerno, E. (2003). Mosby’s pharmacology in nursing (21st ed.). St. Louis: Mosby, p. 1060.
3. A client had a Miller-Abbott tube inserted 24 hours ago. The nurse is asked to check the client to determine whether the tube is in the appropriate location at this time. Which of the following findings would indicate adequate location of the tube?
A. The aspirate from the tube has a pH of 7.45
B. The aspirate from the tube has a pH of 6.5
C. Bowel sounds are absent
D. The tube can be palpated to the right of the umbilicus
Answer: A. The aspirate from the tube has a pH of 7.45
Rationale: The Miller-Abbott tube is a nasoenteric tube that is used to decompress the intestine (to correct a bowel obstruction). The end of the tube should be located in the intestine. The pH of the gastric fluid is acidic, and the pH of the intestinal fluid is 7 or higher if the tube is adequately located. Location of the tube can also be determined by x-ray examination. Options 3 and 4 are incorrect and would not determine adequate location of the tube.
Test-Taking Strategy: The issue of the question is specific content regarding the client with a Miller-Abbott tube with regard to placement and location of the tube. Knowing that this tube should be located in the intestine and recalling that intestinal contents are alkaline will easily direct you to option A. Review the purpose of a Miller-Abbott tube and the nursing care of a client with this tube if you had difficulty with this question.
Level of Cognitive Ability: Analysis
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Evaluation
Content Area: Adult Health/Gastrointestinal
Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 660-662.
4. A nurse is monitoring a client receiving spironolactone (Aldactone) 50 mg by mouth daily. Which of the following would indicate to the nurse that the client is experiencing a side effect related to the medication?
A. A potassium level of 5.2 mEq/L
B. A sodium level of 140 mEq/L
C. Client complaints of constipation
D. Client complaints of dry skin
Answer: A. potassium level of 5.2 mEq/L
Rationale: Spironolactone is a potassium-sparing diuretic. Side effects include hyperkalemia, dehydration, hyponatremia, and lethargy. Although the concern with most diuretics is hypokalemia, this medication is potassium sparing, which means that the concern with the administration of this medication is hyperkalemia. The normal sodium level is 135 to 145 mEq/L, and the normal potassium level is 3.5 to 5.1 mEq/L. Additional side effects include nausea, vomiting, cramping, diarrhea, headache, ataxia, drowsiness, confusion, and fever. Dry skin is unrelated to the administration of this medication.
Test-Taking Strategy: Use the process of elimination. Remember that most diuretics produce hypokalemia; however, the potassium-sparing diuretics cause hyperkalemia, particularly in clients on potassium supplements and clients with renal insufficiency. If you had difficulty with this question, review those medications in the classification of potassium-sparing diuretics.
Level of Cognitive Ability: Analysis
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Data Collection
Content Area: Pharmacology
Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed.). Philadelphia: W.B. Saunders, p. 887.
Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 985.
Source : NCLEX Questions and answer
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