Free Learn NCLEX PN Questions with Rationale 110th Edition

Free Learn NCLEX PN Questions with Rationale 110th Edition

1. Acetylsalicylic acid (aspirin) is prescribed for a client before a percutaneous transluminal coronary angioplasty (PTCA). When the nurse brings the aspirin to the client, the client asks the nurse about its purpose. The nurse informs the client that the aspirin will:

A. Prevent a fever after the procedure
B. Relieve pain at the injection site
C. Prevent the formation of clots
D. Prevent inflammation of the injection site

Answer: C. Prevent the formation of clots

Rationale: Before PTCA, the client is usually given an anticoagulant, commonly aspirin, to help reduce the risk of occlusion of the artery during the procedure. Options 1, 2, and 4 are unrelated to the purpose of administering aspirin to this client.

Test-Taking Strategy: Use the process of elimination and recall the action and properties of aspirin. Options 2 and 4 can be eliminated first because they are similar. Awareness of the potential complications of a PTCA and nursing measures to prevent these complications will help direct you to option 3 from the remaining options. If you had difficulty with this question, review the action and the uses of aspirin and the complications associated with PTCA.

Level of Cognitive Ability: Application
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Adult Health/Cardiovascular
Reference: Skidmore-Roth, L. (2005). Mosby’s drug guide for nurses (6th ed.). St. Louis: Mosby, p. 75.

2. A nurse is caring for a client with coronary artery disease and a topical nitrate is prescribed for the client. The nurse reinforces medication instructions and tells the client that acetaminophen (Tylenol) is usually prescribed to be taken before the administration of the topical nitrate because:

A. Headache is a common side effect of nitrates
B. Acetaminophen potentiates the therapeutic effects of nitrates
C. Acetaminophen does not interfere with platelet action as acetylsalicylic acid (aspirin) does
D. Fever may accompany coronary artery disease

Answer: A. Headache is a common side effect of nitrates

Rationale: Headache occurs as a side effect of nitrates. Acetaminophen may be given before nitrates to prevent headaches or to minimize the discomfort from the headaches. Option 2 is incorrect. Options 3 and 4 are unrelated to the issue of the question.

Test-Taking Strategy: Use the process of elimination. Eliminate option 2 first, because this is an incorrect statement. Although options 3 and 4 are true statements, they do not address the issue of the question. Also, recalling that headache is a common side effect of nitrates will assist in directing you to the correct option. If you had difficulty with this question, review the side effects of nitrates and the purpose of administering acetaminophen before these medications.

Level of Cognitive Ability: Application
Client Needs: Physiological Integrity
Integrated Process: Teaching/Learning
Content Area: Adult Health/Cardiovascular
Reference: Lehne, R. (2004). Pharmacology for nursing care (5th ed.). Philadelphia: W.B. Saunders, p. 533.

3. A nurse is preparing a heparin (Liquaemin) infusion for a client with a diagnosis of thrombophlebitis. The nurse asks a licensed practical nurse (LPN) to gather the necessary items that will be needed for initiating and monitoring the infusion therapy. Which of the following items is unnecessary?

A. Intravenous (IV) infusion controller
B. IV tubing
C. Protamine sulfate
D. Vitamin K (AquaMEPHYTON)

Answer: D. Vitamin K (AquaMEPHYTON)

Rationale: Vitamin K is the antidote for warfarin sodium (Coumadin). Protamine sulfate is the antidote for heparin. IV tubing will be necessary for connection of the IV solution (containing the prescribed heparin dose) to the client’s IV catheter. Heparin is always infused via an IV pump or controller.

Test-Taking Strategy: Note the key word unnecessary. Visualize the process of administration of the heparin infusion. Eliminate options 1 and 2, knowing that IV tubing is necessary and the heparin is always infused by an IV pump or controller. From the remaining options, you must know that the antidote for heparin is protamine sulfate. Review this treatment measure if you had difficulty with this question or are unfamiliar with this medication.

Level of Cognitive Ability: Application
Client Needs: Safe, Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Pharmacology
Reference: Lehne, R. (2004). Pharmacology for nursing care (5th ed.). Philadelphia: W.B. Saunders, pp. 549-564.

4. A nurse is assisting in developing a plan of care for a client who will be returning to the nursing unit following a cardiac catheterization via the femoral approach. Which nursing intervention will be included in the postprocedure plan of care?

A. Place the client in Fowler’s position
B. Encourage the client to increase fluid intake
C. Instruct the client to perform range-of-motion exercises of the extremities
D. Hold precatheterization medications for 24 hours following the procedure

Answer: B. Encourage the client to increase fluid intake

Rationale: Immediately following a cardiac catheterization using the femoral approach, the client should not flex or hyperextend the affected leg. Placing the client in Fowler’s position increases the risk of hemorrhage. Fluids are encouraged to assist in removing the contrast medium from the body. Asking the client to move the toes is done to assess motion, which could be impaired if a hematoma or thrombus were developing. Flexion or hyperextension and range-of-motion exercises of the extremity are contraindicated. The precatheterization medications are needed to treat acute and chronic conditions.

Test-Taking Strategy: Note the key words femoral approach in the question. Visualizing this procedure performed by this approach and thinking about the associated complications will assist you in eliminating options 1 and C. It does not make sense or serve any useful purpose to hold medications from the client following this procedure; therefore select option 2 over option D. Review postcardiac catheterization care if you had difficulty with this question.

Level of Cognitive Ability: Application
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Planning
Content Area: Adult Health/Cardiovascular
Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed.). Philadelphia: W.B. Saunders, p. 328.

Read also:

• Learn NCLEX PN Questions with Rationale 109th Edition
• NCLEX PN with Hard Questions 108th Edition
• Free NCLEX Practice Tests 107th Edition

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