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Answer and Rationale - NCLEX PN Practice Questions 4

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1.      Answer D is correct. Respiratory stridor is a symptom of partial airway obstruction. Answers A, B, and C are expected with a tonsillectomy; therefore, they are incorrect.

2.      Answer C is correct. Pain associated with duodenal ulcers is lessened if the client eats a meal or snack. Answer A is incorrect because it makes the pain worse. Answer B refers to dumping syndrome; therefore, it is incorrect. Answer D refers to gastroesophageal reflux; therefore, it is incorrect.

3.      Answer C is correct. Foods containing rice or millet are permitted on the diet of the client with celiac disease. Answers A, B, and D are not permitted because they contain flour made from wheat, which exacerbates the symptoms of celiac disease; therefore, they are incorrect.

4.      Answer B is correct. Increased thirst and increased urination are signs of lithium toxicity. Answers B and D do not relate to the medication; therefore, they are incorrect. Answer C is an expected side effect of the medication; therefore, it is incorrect.

5.      Answer C is correct. The immunization protects the child against diphtheria, pertussis, tetanus, and H. influenza b. Answer A is incorrect because a second injection is given before 4 years of age. Answer B is not a true statement; therefore, it is incorrect. Answer D is incorrect because it is not a one-time injection, nor does it protect against measles, mumps, rubella, or varicella.

6.      Answer D is correct. The milkshake will provide needed calories and nutrients for the client with mania. Answers A and B are incorrect because they are high in sodium, which causes the client to excrete the lithium. Answer C has some nutrient value, but not as much as the milkshake.

7.      Answer A is correct. The child with intussusception has stools that contain blood and mucus, which are described as "currant jelly" stools. Answer B is a symptom of pyloric stenosis; therefore, it is incorrect. Answer C is a symptom of Hirschsprung’s; therefore, it is incorrect. Answer D is a symptom of Wilms tumor; therefore, it is incorrect.

8.      Answer D is correct. The nurse should not use water, soap, or lotion on the area marked for radiation therapy. Answer A is incorrect because it would remove the marking. Answers B and C are not necessary for the client receiving radiation; therefore, they are incorrect.

9.      Answer A is correct. Growth hormone levels generally fall rapidly after a hypophysectomy, allowing insulin levels to rise. The result is hypoglycemia. Answer B is incorrect because it traumatizes the oral mucosa. Answer C is incorrect because the client’s head should be elevated to reduce pressure on the operative site. Answer D is incorrect because it increases pressure on the operative site that can lead to a leak of cerebral spinal fluid.

10.  Answer C is correct. Precose (acarbose) is to be taken with the first bite of a meal. Answers A, B, and D are incorrect because they specify the wrong schedule for medication administration.

11.  Answer B is correct. The client going for therapy in the hyperbaric oxygen chamber requires no special skin care; therefore, washing the skin with water and patting it dry are suitable. Lotions, petroleum products, perfumes, and occlusive dressings interfere with oxygenation of the skin; therefore, answers A, C, and D are incorrect.

12.  Answer C is correct. The primary reason for the NG to is to allow for nourishment without contamination of the suture line. Answer A is not a true statement; therefore, it is incorrect. Answer B is incorrect because there is no mention of suction. Answer D is incorrect because the oral mucosa was not involved in the laryngectomy.

13.  Answer A is correct. The client with expressive aphasia has trouble forming words that are understandable. Answer B is incorrect because it describes receptive aphasia. Answer C refers to apraxia; therefore, it is incorrect. Answer D is incorrect because it refers to agnosia.

14.  Answer D is correct. Sunscreens of at least an SPF of 15 should be applied 20–30 minutes before going into the sun. Answers A, B, and C are incorrect because they do not allow sufficient time for sun protection.

15.  Answer B is correct. The combination of the two medications produces an effect greater than that of either drug used alone. Agonist effects are similar to those produced by chemicals normally present in the body; therefore, answer A is incorrect. Antagonist effects are those in which the actions of the drugs oppose one another; therefore, answer C is incorrect. Answer D is incorrect because the drugs would have a combined depressing, not excitatory, effect.

16.  Answer C is correct. The medication should be withheld and the doctor should be notified. Answers A, B, and D are incorrect because they do not provide for the client’s safety.

17.  Answer B is correct. Solid foods should be added to the diet one at a time, with 4- to 7-day intervals between new foods. The extrusion reflex fades at 3–4 months of age; therefore, answer A is incorrect. Answer C is incorrect because solids should not be added to the bottle and the use of infant feeders is discouraged. Answer D is incorrect because the first food added to the infant’s diet is rice cereal.

18.  Answer C is correct. The client’s symptoms suggest an adverse reaction to the medication known as neuroleptic malignant syndrome. Answers A, B, and D are not appropriate.

19.  Answer D is correct. The client with HIV should adhere to a low-bacteria diet by avoiding raw fruits and vegetables. Answers A, B, and C are incorrect because they are permitted in the client’s diet.

20.  Answer C is correct. The child with leukemia has low platelet counts, which contribute to spontaneous bleeding. Answers A, B, and D, common in the child with leukemia, are not life-threatening.

21.  Answer A is correct. The nurse should prevent the infant with atopic dermatitis (eczema) from scratching, which can lead to skin infections. Answer B is incorrect because fever is not associated with atopic dermatitis. Answers C and D are incorrect because they increase dryness of the skin, which worsens the symptoms of atopic dermatitis.

22.  Answer D is correct. Symptoms associated with diverticulitis are usually reported after eating popcorn, celery, raw vegetables, whole grains, and nuts. Answers A, B, and C are incorrect because they are allowed in the diet of the client with diverticulitis.

23.  Answer B is correct. The Whipple procedure is performed for cancer located in the head of the pancreas. Answers A, C, and D are not correct because of the location of the cancer.

24.  Answer C is correct. Side effects of Pulmozyme include sore throat, hoarseness, and laryngitis. Answers A, B, and C are not associated with Pulmozyme; therefore, they are incorrect.

25.  Answer B is correct. The nurse should be concerned with alleviating the client’s pain. Answers A, B, and C are not primary objectives in the care of the client receiving an opiate analgesic; therefore, they are incorrect.


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