NCLEX PN Questions Test Bank 2020 / 2021 117th Edition

NCLEX PN Questions Test Bank 2020 / 2021 117th Edition

1. A client with Graves’ disease has exophthalmos and is experiencing photophobia.

Which intervention would best assist the client with this problem?

A. Administer methimazole (Tapazole) every 8 hours around the clock
B. Lubricate the eyes with tap water every 2 to 4 hours
C. Instruct the client to avoid straining or heavy lifting since this can increase eye pressure
D. Obtain dark glasses for the client

Answer: D. Obtain dark glasses for the client

Rationale: Medical therapy for Graves’ disease does not help to alleviate the clinical manifestation of exophthalmos. Since photophobia (light intolerance) accompanies this disorder, dark glasses are helpful in alleviating the symptom. Other interventions may be used to relieve the drying that occurs from not being able to completely close the eyes; however, the question is asking what the nurse can do for photophobia. Tap water, which is hypotonic, could actually cause more swelling to the eye since it could pull fluid into the interstitial space. In addition, there is a risk of an eye infection developing in the client since the solution is not sterile. There is no need to prevent straining with exophthalmos.

Test-Taking Strategy: Focus on the issue, photophobia. Knowledge of what photophobia means will help you to answer the question. Methimazole, a medical treatment for Graves’ disease, does not affect the progression of exophthalmos or alleviate the photophobia. Likewise options 2 and 3 will not relieve the photophobia. Review the measures that relieve photophobia if you had difficulty with this question.

Level of Cognitive Ability: Application
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Adult Health/Endocrine
Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders,
pp. 1255-1256.

2. A nurse is assigned to care for a client who had a subtotal thyroidectomy. The nurse reviews the plan of care and determines that the priority nursing diagnosis for this client in the immediate postoperative period would be which of the following?

A. Risk for deficient fluid volume related to T3 and T4 deficits promoting sodium and water loss
B. Risk for infection related to high glucose levels following removal of the thyroid
C. Risk for decreased cardiac output related to hemorrhage
D. Risk for impaired urinary elimination related to hypercalcemia and renal calculi formation

Answer: C. Risk for decreased cardiac output related to hemorrhage

Rationale: Hemorrhage is one of the most severe complications that can occur following thyroidectomy. The nurse must check the neck dressing for bleeding and monitor vital signs frequently to detect early signs of hemorrhage, which could lead to shock. T3 and T4 do not regulate fluid volumes in the body. Removal of the thyroid may affect glucose levels indirectly, but will not put the client at risk for infection. This is a problem more likely to be seen with a client with uncontrolled diabetes mellitus. Hypercalcemia and renal calculi are associated with hyperparathyroidism.

Test-Taking Strategy: Focus on the key words priority and immediate postoperative period. Knowledge of thyroid function will assist to eliminate options 1, 2, and D. Also, use the ABCs—airway, breathing, and circulation. Circulation will be affected if hemorrhage develops. Review care to the client following thyroidectomy if you had difficulty with this question.

Level of Cognitive Ability: Analysis
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Planning
Content Area: Adult Health/Endocrine
Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, pp. 885-886.

3. A nurse is assisting in caring for a client with pneumonia who suddenly becomes restless. Arterial blood gases are drawn, and the results reveal a PaO2 of 60 mm Hg. The nurse reviews the plan of care for the client and determines that which nursing diagnosis would be most appropriate?

A. Fatigue related to debilitated state
B. Impaired gas exchange related to increased pulmonary secretions
C. Ineffective airway clearance related to dilated bronchioles
D. Impaired gas exchange related to pneumonia

Answer: B. Impaired gas exchange related to increased pulmonary secretions

Rationale: Restlessness and low PaO2 are hallmark signs of impaired gas exchange. Although many clients with pneumonia experience fatigue, this diagnosis would not be the most appropriate because of the low PaOB. Dilated bronchioles would be a goal for treatment and not part of the problem. Pneumonia is a medical diagnosis.

Test-Taking Strategy: Use the process of elimination. Avoid nursing diagnoses that address a medical diagnosis; therefore eliminate option D. Eliminate option 1 next because it is unrelated to the issue. From the remaining options, knowing that the bronchioles are not dilated in pneumonia will assist in directing you to option B. Review care to the client with pneumonia and the defining characteristics for impaired gas exchange if you had difficulty with this question.

Level of Cognitive Ability: Analysis
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Planning
Content Area: Adult Health/Respiratory
Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, pp. 481-483.

4. A client with tuberculosis (TB) is started on rifampin (Rifadin). The nurse teaches the client about the medication and tells the client:

A. Not to worry about jaundice because an orange discoloration of the skin is common
B. To wear glasses instead of soft contact lenses
C. To always take the medication on an empty stomach
D. That as soon as the cultures come back negative the medication may be stopped

Answer: B. To wear glasses instead of soft contact lenses

Rationale: Soft contact lenses may be permanently damaged by the orange discoloration that rifampin causes in body fluids. Any sign of jaundice should always be reported. If rifampin is not tolerated on an empty stomach, it may be taken with food. The client may be on the medication for 12 months even if cultures are negative.

Test-Taking Strategy: Use the process of elimination. Eliminate option 1 because an orange discoloration of the skin indicates jaundice and should be reported. Eliminate option 3 next because of the absolute word “always.” From the remaining options, use knowledge of the actions and uses of rifampin and the treatment for TB to direct you to option B. Review this medication if you had difficulty with this question.

Level of Cognitive Ability: Application
Client Needs: Health Promotion and Maintenance
Integrated Process: Teaching/Learning
Content Area: Pharmacology
Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 939.

Read also:

• Free NCLEX Questions Test Bank 2020 / 2021 116th Edition
• Free NCLEX Questions Test Bank 2020 / 2021 115th Edition
• NCLEX Questions Test Bank 2020 / 2021 114th Edition

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