Blog about quiz / question and answer NCLEX (National Council Licensure Examination) For Nursing Student, Example Question NCLEX RN and NCLEX PN. Exam for Nurse
1. A client sustains a burn injury to the entire right and left arms, right leg, and anterior thorax. According to the “rule of nines,” the nurse would determine that this injury constitutes which of the following body percentages?
A. 27%
B. 36%
C. 45%
D. 54%
Answer: D. 54%
Rationale: According to the “rule of nines,” the right arm is equal to 9% and the left arm is equal to 9%. The right leg is equal to 18% and the left leg is equal to 18%. The anterior thorax is equal to 18% and the posterior thorax is equal to 18%. The head is equal to 9% and the perineum is 1%. If the anterior thorax, the right leg, and the right and left arms were burned, the area of injury would equal 54% according to the “rule of nines.”
Test-Taking Strategy: Knowledge of the percentages associated with the “rule of nines” is required to answer this question. From this point, you would be able to determine the percentage of burn injury and use the process of elimination to select the correct option. Review the rule of nines 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/Integumentary
Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 90.
2. A nurse is collecting neurological data on a poststroke adult client. Which of the following techniques will the nurse perform to adequately check proprioception?
A. Firmly stroke the lateral sole of the foot and under the toes with a blunt instrument
B. Tap the Achilles tendon using the reflex hammer
C. Gently prick the client’s skin on the dorsum of the foot in two places
D. Hold the sides of the client’s great toe and, while moving it, ask the client to describe the toe’s position
Answer: D. Hold the sides of the client’s great toe and, while moving it, ask the client to describe the toe’s position
Rationale: Proprioception is tested by holding the sides of the client’s great toe and, while moving it, asking the client to describe the toe’s position. The plantar reflex is elicited in option A. Normally, the toes plantar-flex, but in an abnormal reflex, the toes dorsiflex and fan out. Option 2 identifies the assessment for gastrocnemius muscle contraction, and option 3 tests two-point discrimination.
Test-Taking Strategy: Knowledge of general neurological data collection techniques is helpful in answering this question. Note the relationship between the term “proprioception” in the question and the word “position” in the correct option. Review general neurological assessment if you had difficulty with this question.
Level of Cognitive Ability: Application
Client Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process/Data Collection
Content Area: Adult Health/Neurological
Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, p. 933.
3. A nurse is providing instructions to a client with otitis media receiving amoxicillin (Amoxil) 500 mg orally every 8 hours. Which of the following statements by the client would indicate an understanding of the adverse effects related to the medication?
A. “A headache may mean that I need to discontinue the medication.”
B. “I may become dizzy from the medication.”
C. “Constipation means that the medication needs to be stopped.”
D. “If I get diarrhea, I need to call the doctor.”
Answer: D. “If I get diarrhea, I need to call the doctor.”
Rationale: Amoxicillin is a penicillin. Adverse reactions include superinfections such as potentially fatal antibiotic-associated colitis, which results from altered bacterial balance. Symptoms include abdominal cramps, severe watery diarrhea, and fever. Frequent side effects include gastrointestinal (GI) disturbances, headache, and oral or vaginal candidiasis. Options 1, 2, and 3 are incorrect.
Test-Taking Strategy: Note the key words understanding of the adverse effects. Remember, antibiotics have a tendency to produce GI side effects. If you can remember that this medication is classified as an antibiotic, you will select option 4 by the process of elimination. Review the adverse effects of 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. 60.
4. A nurse is providing instructions to a client with glaucoma receiving acetazolamide (Diamox) daily. Which of the following statements by the client indicates an understanding of the adverse effects related to the medication?
A. “Constipation will probably be a problem with this medication.”
B. “If difficulty with swallowing occurs, I need to taper the medication.”
C. “I need to call the doctor if I get dark-colored urine and stools.”
D. “If I get really irritable, I need to stop the medication.”
Answer: C. “I need to call the doctor if I get dark-colored urine and stools.”
Rationale: Acetazolamide is a carbonic anhydrase inhibitor. Nephrotoxicity and hepatotoxicity occur and are manifested by dark-colored urine and stools, pain in the lower back, jaundice, dysuria, crystalluria, renal colic, and calculi. Bone marrow depression also may occur. Options 1, 2, and 4 are incorrect client statements.
Test-Taking Strategy: Use the process of elimination. Eliminate options 2 and 4 first, using general principles related to medication therapy. The client should not taper or stop medication without physician consultation. Noting the key words adverse effects in the question will assist in directing you to option C. Additionally, remembering that acetazolamide is nephrotoxic and hepatotoxic will assist in directing 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/Evaluation
Content Area: Pharmacology
Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 10.
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