NCLEX Questions with Answers and Rationale 81th Edition

NCLEX Questions with Answers and Rationale 81th Edition

1. A nurse has reinforced discharge instructions to a mother of a child who is taking tetracycline hydrochloride (Achromycin) to treat Rocky Mountain spotted fever (RMSF). Which statement by the mother indicates the best understanding regarding the administration of the medication?

A. “I need to give the medication with water.”
B. “I need to give the medication with milk.”
C. “I need to mix the medication in a Styrofoam glass with water.”
D. “I need to use a straw when I give the medication.”

Answer: D. “I need to use a straw when I give the medication.”

Rationale: Because tetracycline hydrochloride can cause staining of the teeth, straws should be used, and the mouth should be rinsed after administration. Option 3 is not necessary. The medication should be administered 1 hour before or 2 hours after the administration of milk. Option 1 is accurate, but the best measure is to administer the medication with a straw.

Test-Taking Strategy: Focus on the medication. Recalling that tetracycline can cause staining of the teeth will direct you to option D. If you had difficulty with this question, review the client teaching points related to the administration of this medication.

Level of Cognitive Ability: Comprehension
Client Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process/Evaluation
Content Area: Pharmacology
Reference: McKenry, L., & Salerno, E. (2003). Mosby’s pharmacology in nursing (21st ed.). St. Louis: Mosby, p. 997.

2. A nurse has reinforced discharge instructions to a client with multiple sclerosis who is receiving baclofen (Lioresal). Which statement by the client indicates an understanding of the medication?

A. “I need to restrict my fluid intake while I take this medication.”
B. “If I experience fatigue, I need to notify the physician.”
C. “I need to stop the medication if diarrhea occurs.”
D. “I need to watch for urinary retention.”

Answer: D. “I need to watch for urinary retention.”

Rationale: Baclofen is a central nervous (CNS) depressant. It is not necessary to restrict fluids, but the client should be warned that urinary retention can occur. Fatigue is related to a CNS effect that is most intense during the early phase of therapy and diminishes with continued medication use. It is not necessary that the client notify the physician. Constipation rather that diarrhea is an adverse effect of baclofen. Additionally the client should be cautioned against the use of alcohol and other CNS depressants since baclofen potentiates the depressant activity of these agents.

Test-Taking Strategy: Use the process of elimination. Recalling that baclofen is a CNS depressant will direct you to option D. If you were unsure of the correct answer, use general principles related to medication administration to assist in selecting the correct option. Review the client teaching points related to this medication if you had difficulty with this question.

Level of Cognitive Ability: Comprehension
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Evaluation
Content Area: Pharmacology
Reference: McKenry, L., & Salerno, E. (2003). Mosby’s pharmacology in nursing (21st ed.). St. Louis: Mosby, p. 512.

3. A nurse employed in the emergency room is preparing to administer syrup of ipecac to a 7-month-old child. The nurse prepares 5 mL of the syrup and administers one half of a glass of water following administration of the ipecac syrup. Which of the following expected response would the nurse expect to occur?

A. Vomiting
B. Diarrhea
C. Increased level of consciousness
D. Elevated blood pressure

Answer: A. Vomiting

Rationale: Syrup of ipecac is a medication that may be prescribed for the induction of emesis. It is indicated following ingestion of some poisons. It is contraindicated following ingestion of strong acids or bases. It is also contraindicated for clients who are comatose, delirious, or experiencing convulsions. The dose for children under 1 year of age is 5 to 10 mL followed by one half to one glass of water. Diarrhea may occur as a side effect of the medication, as can sedation. Blood pressure is not related to administration of this medication.

Test-Taking Strategy: Use the process of elimination and note the key words “expected response.” Eliminate option 2 because diarrhea is a side effect of the medication. Eliminate option 4 because an elevated blood pressure is unrelated to the administration of this medication. From the remaining options, recalling that an oral medication would not be given if the child is not alert would assist in directing you to option A. Review this medication if you had difficulty with this question.

Level of Cognitive Ability: Analysis
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Evaluation
Content Area: Pharmacology
Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 584.

4. L-asparaginase (Elspar) is administered to a client with acute lymphocytic leukemia. The nurse assisting in caring for the client is monitoring for adverse effects related to the medication. Which of the following, if noted on data collection, would indicate toxicity related to the administration of this medication?

A. Altered coagulation blood studies
B. Decreased white blood cell count
C. Oral ulcerations
D. Alopecia

Answer: A. Altered coagulation blood studies

Rationale: L-asparaginase can cause severe adverse effects, however the spectrum of toxicity differs from that of other anticancer medications. By inhibiting protein synthesis, the medication can cause coagulation deficiencies and injury to the liver, pancreas, and kidneys. Symptoms of central nervous system depression ranging from confusion to coma can occur. Nausea and vomiting can be intense and may limit the dose that can be tolerated. In contrast to most anticancer medications, L-asparaginase does not depress the bone marrow, nor does it cause alopecia, oral ulceration, or intestinal ulceration.

Test-Taking Strategy: Use the process of elimination. Recalling that the toxicity associated with this medication is different from most anticancer medications will assist in directing you to option A. Review the toxic effects of this medication if you had difficulty with this question.

Level of Cognitive Ability: Analysis
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, pp. 85-86.

Source : NCLEX Questions and answer

Like & Visit Our Facebook Fanspage at : https://www.facebook.com/NCLEX-Exam-for-Pass-103898044308313/

Read also:

• Example of NCLEX Questions, Answers with Rationale and Test-Taking Strategy 80th Edition
• Example of NCLEX Question pdf doc 2019 / 2020 79th Edition
• Example of Hard NCLEX Question 78th Edition

Thank you for your attention with reading our article NCLEX Questions with Answers and Rationale 81th Edition. Thanks for your participation, like and share if this is usefull.

Share this post