NCLEX-PN National Council Licensure Examination(NCLEX-PN) Question and Answers

Health promotion activities are designed to help clients reduce the risk of illness, maintain maximum

function, and promote health habits related to health care.Health Promotion and Maintenance

By definition, case management is a process of providing for the comprehensive care needs of a client for

continuity of care throughout the health care experience.Coordinated Care

All of the choices are anti-HIV drugs.Safety and Infection Control

The most common type of first-degree burn is sunburn, underscoring the need for education regarding the use

of sunscreens and avoiding exposure.Safety and Infection Control

A false-positive result occurs when a test result is labeled positive in error, when the actual result is negative.

Safety and Infection Control

Barriers to reporting elder abuse include victim shame, fear of reprisals, fear of loss of caregiver, and lack of

knowledge of agencies that provide services. Many elders fear that reporting abuse results in their placement in

long-term care because the current caregiver is the abuser. Choices 1 and 3 are incorrect. Choice 2 might be true

but is not the best choice.Psychosocial Integrity

Legal protection of confidentiality extends to both written and verbal information identifiable as individual

private health information.Coordinated Care

The vast majority of deaths resulting from unintentional poisoning occur in toddlers.Safety and Infection

Control

Questions should be asked in a precise order (specifically, from the most-simple description to the moredifficult

disclosure of feelings). When the problems have been described, eliciting the client’s thoughts about the

dilemmas provides further assessment data as well as the client’s interpretation of what has happened. Feelings,

solutions and articulating intent are more complex processes.Psychosocial Integrity

Facilitating the development of staff members is an important goal for a supervisor. Micromanagement,

intolerance for individual differences in style, and inability to delegate all interfere with team building and overall

effectiveness.Coordinated Care

Small volumes of medication or fluids are delivered and sometimes at slow rates to neonates and pediatric clients. The syringe pump allows precise infusion of small volumes. Choice 1 is incorrect because a syringe pump can be used in almost any setting, but is not generally for adult clients. Choices 2 and 3 are incorrect because large volumes of fluids are not administered with a syringe pump.Pharmacological Therapies

A sense of restored body integrity is an expected outcome for interventions related to disturbed body image.

Adequate tissue perfusion is an outcome for risk of injury and risk of infection, not disturbed body image.

Demonstrating behaviors that might reduce fears is an outcome for anxiety. Remaining free of infection is an

outcome for risk of infection.Health Promotion and Maintenance

The nurse must be aware of cultural practices that resemble child abuse. These practices include coining, cupping, and fallen fontanella. Coining and cupping are thought to draw infections from the body. Coining involves rubbing a heated coin on the chest and torso and might cause bruising. Cupping uses heated glasses that can produce erythematous and ecchymotic rounded lesions or linear streaks on the body from the suction. Fallen fontanella involves turning a child upside down to correct a depressed fontanelle; it can cause vomiting, diarrhea, and dehydration in infants. Retinal hemorrhages can also occur, and sometimes Shaken-Baby Syndrome is erroneously diagnosed.Psychosocial Integrity

Topical agents produce a localized, rather than systemic, effect. When treating atopic dermatitis with a steroidal preparation, the site is vulnerable to invasion by organisms. Viruses, such as herpes simplex or varicella zoster, present a risk of disseminated infection. Educate the client using topical corticosteroids to avoid crowds or people known to have infections and to report even minor signs of an infection. Topical corticosteroid use results in little danger of concurrent infection with the agents in choices 1, 3, and 4.Pharmacological Therapies

Displacement unconsciously transfers emotions associated with a person, object, or situation to another lessthreatening person, object, or situation. The nurse slammed doors instead of striking the promoted nurse or the administrator who made the promotion decision. Sublimation is the unconscious process of substituting constructive activity for unacceptable impulses. This choice cannot be considered correct because the slamming of the cupboard doors cannot be considered a constructive activity. Conversion involves unconsciously transforming anxiety into a physical symptom. Reaction formation keeps unacceptable feelings or behaviors out of awareness by using the opposite feeling or behavior.Psychosocial Integrity

Some studies have shown that ginseng and astragalus have enhanced in vitro sperm motility. Ginseng has long been used in traditional Chinese medicine to enhance male fertility. So, Choice 2 is correct and directly addresses the client’s comments. Many times couples struggling with infertility turn to alternative therapies in desperation. They can be very expensive, and some are harmful. Ginseng should not interfere with any of the traditional fertility treatments and might help the couple feel empowered that they are also doing something on their own. Choice 1 is not true. Choice 3 introduces another alternative therapy. It is true that acupuncture is a traditional Chinese medical therapy and has been shown in several clinical studies to be effective in treating infertility in both women and men. The best response by the nurse should address the therapy the client states she is using. Choice 4 dismisses the client’s attempts to work through her issues and contribute to the solution. One concern is always that more traditional therapies might be ignored, and time might be lost to alternative therapies. But this response causes the client to perceive the nurse as unsupportive and inhibits further discussion and disclosure.Health Promotion and Maintenance

Compazine is the drug that should be administered.Basic Care and Comfort

A high bilirubin level is found with hepatic immaturity in newborns, from which jaundice results. The other

choices are not.Reduction of Risk Potential

Guillain-Barré syndrome has a severe complication of respiratory failure. The remaining choices are peripheral nerve conditions, like Guillain-Barré. However, they do not lead to such a severe complication.Reduction of Risk Potential

When a client is in a hepatic coma, he is in live liver failure. The liver can no longer metabolize amino acids

completely, thus ammonia levels increase causing brain-tissue irritation.Basic Care and Comfort

Naprosyn might cause upper-gastrointestinal (UGI) bleeding.Reduction of Risk Potential

Cold applications are believed to produce vasoconstriction and reduce development of edema. Disability and

pain are anticipated to increase during the first 2–3 hours after injury. Progressive passive and active exercises

may begin in 2–5 days, according to the physician’s recommendation. A sprain is a traumatic injury to the

tendons, muscles, or ligaments around a joint, characterized by pain, swelling, and discoloration of the skin over

the joint. The duration and severity of the symptoms vary with the extent of damage to the supporting tissues.

Treatment requires support, rest, and alternating cold and heat. X-ray pictures are often indicated to be certain

that no fracture has occurred.Physiological Adaptation

Ten seconds is the usual amount of time the nurse should spend for each suction pass. Two seconds is not

enough time to remove secretions. The remaining choices are too long and could lead to hypoxia and tissue

trauma.Reduction of Risk Potential

Jaundice turns the skin yellow. The other skin colors are not symptoms of jaundice.Physiological Adaptation

Sex role identification begins during infancy. Infants can identify body parts by the end of the first year. Preschoolers frequently engage in masturbation and sex play with peers. School-age children continue to gain awareness of their sexual identity. During this time they might continue to masturbate and engage in sex play. They might add behaviors such as hugging and kissing members of the opposite sex. Adolescent sex role identification is largely influenced by sexual maturation and trying out or assuming a sex role.Health Promotion and Maintenance

For the client with an NG tube who begins vomiting, the nurse should check the tube placement because

it might be displaced, thereby leading to vomiting. The other responses are not appropriate.Reduction of Risk

Potential

Moving a joint through the full range of motion identifies limitation of movement.Basic Care and Comfort

Immediately postop abdominal surgery, the NG tube keeps the stomach decompressed to prevent surgical-site

disruption and fluid loss through vomiting.Basic Care and Comfort

His wife is exhibiting obsessive-compulsive behavior. Because this is an anxiety disorder, it is desirable to maintain an environment that is calm and as stress free as possible. Attempting to stop or focusing on the behavior can increase the wife’s anxiety and therefore the repetitive behavior.Psychosocial Integrity

A strain is excessive stretching of a ligament. A sprain involves a twisting motion involving muscles.Basic

Care and Comfort

Scurvy is associated with inadequate intake of vitamin C. The remaining choices refer to other nutritional

deficiencies.Health Promotion and Maintenance

Underarm deodorant should not be used because it might cause confusing shadows on the X-ray film. There

are no restrictions on food or fluid intake. No sedation is used, so the client can drive herself home.Reduction of

Risk Potential

There are several guidelines for evaluating kinetic family drawings, including Choice 4. Effective nursing

actions include asking the child to explain what each family member is doing, encouraging him or her to tell as

much as possible about the drawing, noting physical intimacy or distance, noting placement of family members in

the drawing, noting facial expressions of family members and noting if they are facing each other or turned away.

Choice 1 is initial instruction, not evaluation. Only general encouragement should be given to avoid suggesting

themes to the child.Health Promotion and Maintenance

Trauma in any client, living or dead, has potential legal and/or forensic implications. Clothing, patterns of

stains, and debris are sources of potential evidence and must be preserved. Nurses must be aware of state and

local regulations that require mandatory reporting of cases of suspected child and elder abuse, accidental death,

and suicide. Each Emergency Department has written policies and procedures to assist nurses and other health

care providers in making appropriate reports. Physical evidence is real, tangible, or latent matter that can be

visualized, measured, or analyzed. Emergency Department nurses can be called on to collect evidence. Health

care facilities have policies governing the collection of forensic evidence. The chain of evidence custody must

be followed to ensure the integrity and credibility of the evidence. The chain of evidence custody is the pathway

that evidence follows from the time it is collected until is has served its purpose in the legal investigation of an

incident.Physiological Adaptation

Teaching the client and family about progression of the disease includes explaining when symptoms can

be expected to improve and resolve. Knowledge of the course of the disease can help them understand that no

permanent disruption in physical appearance will occur that could negatively affect body image. Clients with

Kawasaki disease might receive immune globulin intravenously to reduce the incidence of coronary artery lesions

and aneurysms. Cardiac effects could be linked to body image, but Choice 3 is the most direct link to body image.

The nurse assesses symptoms to assist in evaluation of treatment and progression of the disease.Health

Promotion and Maintenance

Glucose is monitored closely when a client is on total parenteral nutrition, due to high glucose concentration

in the solutions. The other values are not monitored as closely.Health Promotion and Maintenance

Parents should be taught to wash their hands before and after providing cord care. This prevents transferring

pathogens to and from the cord. Folding the diaper below the cord exposes the cord to air and allows for drying.

It also prevents wet or soiled diapers from coming into contact with the cord. Current recommendations include

cleaning the area around the cord 3–4 times a day with a cotton swab but do not include putting alcohol or other

antimicrobials on the cord. It is normal for the cord to turn dark as it dries.Health Promotion and Maintenance

The nurse should change the intravenous tubing on total parenteral nutrition solutions every 24 hours, due to

the high risk of bacterial growth.Health Promotion and Maintenance

Breast implants can prevent detection of masses. Choices 1, 2, and 3 are not ways in which breast implants

interfere with mammography.Reduction of Risk Potential

Eggs are a complete protein. The remaining options are incomplete proteins.Health Promotion and

Maintenance

Assessment for adequate circulation is necessary. Signs of impaired circulation include slow capillary refill,

cool fingers or toes, and pain.Basic Care and Comfort

The small intestine has a primary function of absorption. The remaining digestive organs have other primary

functions.Physiological Adaptation

This statement reassures the client that there is a solution for relief of his anxiety. The other responses minimize the client’s feelings.Reduction of Risk Potential

Toradol is the first injectable NSAID equal to morphine in efficacy.Basic Care and Comfort

Herbal therapy is used to treat many common complaints and diseases.Physiological Adaptation

Anticonvulsants (such as Dilantin), tranquilizers, barbiturates, and other sedatives should be held 24–48 hours prior to an EEG. The other medications do not fall into these classifications.Reduction of Risk Potential

Epidemiological studies indicate that chlamydia is the most prevalent sexually transmitted disease in the United States.Physiological Adaptation

All of the strategies listed are included in home care for the client with Cushing’s syndrome. Choice 3 is the best answer because wearing a medical ID is a visible sign that something is wrong and a constant reminder to the client that he or she has a loss of body function. Choice 1 might enhance body image because it prevents falls that could cause further injury and debilitation. Taking medications as prescribed should enhance body image because it decreases the symptoms present. Having regular health assessments indicates an enhanced body image because it signals the desire to take care of the body and keep it at its best.Health Promotion and Maintenance

Leptin (recessive obesity gene—protein hormone) is expressed in fat cell coding for the protein that reacts to the percentage of fat cells in the body. Leptin is associated with increased energy expenditure and decreased food intake via hypothalamic control. Obese clients might have insensitivity or resistance to the effects of leptin. Leptin can affect other body hormones such as insulin. Genetic factors include leptin, uncoupling proteins, and the amount of brown/white fat in the body.Physiological Adaptation

The blood pressure should be checked first for a client who has just vomited 300 cc of bright red blood, to determine whether the client is hypotensive. The other actions can be taken later.Reduction of Risk Potential

Part of the problem for anorexic clients is an altered view of their body appearance (visualizing themselves as fat even when they are emaciated). Choice 1 involves a knowledge deficit. Choice 2 involves possible resolution of family-dynamic issues. Choice 4 involves psychological adaptation.Basic Care and Comfort

The likelihood of fathering children does decrease with aging and decreased testosterone production, but men do not lose their ability to reproduce during the climacteric. Many men do not experience any physical symptoms of climacteric but some men do report hot flashes, headaches, and heart palpitations, among other symptoms.Health Promotion and Maintenance

Kegel exercises might be prescribed to strengthen the pelvic floor muscles of a client with urinary incontinence.Physiological Adaptation

Alcoholism places a client at risk for developing cirrhosis. None of the other choices are related to cirrhosis.Physiological Adaptation

Choice 3 not only acknowledges the client’s fear but invites more disclosure and discussion. Reflective listening is very therapeutic and in this case acknowledges the woman’s unspoken fear that she might become depressed like her mother. When her fears have been acknowledged and she feels that the nurse understands, she will be more open to the teaching or interventions to follow. It is a myth that menopause causes depression, but to say that to this client does not acknowledge the fear she shared with the nurse and gives the impression the nurse doesn’t care about her concern. It closes down communication. It is also true that menopause is a normal developmental process. This can certainly be used in teaching but not to address her immediate concern; the client might feel the nurse doesn’t think her concern is appropriate because menopause is normal. If women experience depression during menopause, it is usually due to social stresses such as loss of loved ones, loss of roles, caregiver demands, and physical problems. Choice 4 is true but is a nontherapeutic response in this situation.Health Promotion and Maintenance

The least important factor (of those listed) during an emergency situation is the number of accompanying family members.Safety and Infection Control

Caucasians have the highest incidence of inflammatory bowel disease (IBD).Reduction of Risk Potential

Human chorionic gonadotropin is found in the urine during pregnancy and specifically indicates pregnancy. The other hormones do not.Reduction of Risk Potential

This statement reflects cultural awareness and acceptance that receiving support from a medicine woman is

important to the client. The other statements are culturally insensitive and unprofessional.Reduction of Risk

Potential

Unexplained vaginal bleeding is a contraindication for hormone replacement therapy. Family history of

stroke is not a contraindication for hormone replacement therapy. If the woman herself had a history of stroke or

other blood-clotting events, hormone therapy could be contraindicated. Frequent hot flashes and/or night sweats

can be relieved by hormone replacement therapy.Health Promotion and Maintenance

Somatizing means one experiences an emotional conflict as a physical symptom. Ashley manifests several

physical symptoms associated with severe anxiety. Acting out refers to behaviors such as anger, crying, laughter,

and physical or verbal abuse. Withdrawal is a reaction in which psychic energy is withdrawn from the environment

and focused on the self in response to anxiety. Problem-solving takes place when anxiety is identified and the

unmet need is met.Psychosocial Integrity

A synthetic gown might generate sparks of static electricity, which can be a fire hazard, particularly in the

presence of oxygen. The client on oxygen therapy should wear a cotton gown. The remaining options are

appropriate safety measures.Reduction of Risk Potential

Drug tolerance is characterized by the ability to ingest a larger dose without adverse effect and decreased

sensitivity to the substance. Substance dependence is a severe condition indicating physical problems and

disruption of the person’s social, family, and work life. The psychological behaviors related to substance use are

termed addiction. Dual diagnosis is the coexistence of substance abuse and psychiatric disorders.Psychosocial

Integrity

The Health Belief Model describes readiness factors; the perceived feelings of susceptibility and seriousness

of the health problem (the threat); and positive motivation to maintain, regain, or attain wellness.Health

Promotion and Maintenance

The exploration of life problems of support-team members is not necessary to enhance the support system.

Choices 1, 2, and 4 are all enhancements for a support system.Psychosocial Integrity

The client’s legally responsible party may make the decision for organ donation if the client is unable to do so.

The donor (or legally responsible party for the donor), the physician, and the organ-procurement organization are

all involved in the process regarding whether organ donation is appropriate for a specific donor.Coordinated Care

Using a direct approach is best when asking about suspected abuse. Clients are reluctant to report abuse

because of shame and fear of reprisal.Psychosocial Integrity

All the choices are elements of the ANA Code of Ethics for Nurses.Coordinated Care

Chemotherapy causes damage to cells, and uric acid is a cell metabolite.Physiological Adaptation

The nurse should stand about 6 feet from the source of the fire. Getting closer might put the nurse in danger.Safety and Infection Control

Muscle spasms and restlessness are side effects of Haldol

Monitoring cardiac status is of the highest priority. Permanent cardiac damage can result from rheumatic fever. The second priority is assessing the client’s joints for the presence of polyarthritis and accompanying pain.Physiological Adaptation

A-C are associated side effects of Klonapin.

A determination of arterial blood flow should be made, prior to encouraging increased activity, or notifying additional team members.

Pain may be indicating neurovascular complication.

Seclusion is your best option in this scenario.

Lidocaine Hydrochloride can cause fatigue and confusion if an over dosage occurs.

Beta cells secrete insulin.

At least 10% of victims of childhood sexual abuse have periods of complete amnesia about the abuse, followed by delayed recall. Controversial evidence suggests that people who have recovered memories have had part of those memories reconstructed by therapists. The nurse’s role is not to determine if the memories are real, but to help the client deal with the stress caused by the remembered abuse.Psychosocial Integrity

The bicarbonate value is below normal, indicating a condition of metabolic acidosis.

Edema in the lower extremities may indicate a Premarin (over-dosage).

Floxin is a quinolone antibiotic used in respiratory infections and pelvic and reproductive infections. Rarely, quinolones can cause tendon sheath rupture, usually of the Achilles. At the first indication of tendon pain, the antibiotic should be discontinued.Safety and Infection Control

Breath sounds would be softer.

The suicide plan may have been decided.

The Good Samaritan laws protect providers of care in an emergency situation. HIPAA’s focus is confidentiality of information and right to privacy. The PSDA concerns a client’s autonomous decision-making. OBRA was passed in the late 1980s to promote nursing home reform due to quality issues.Coordinated Care

The Mantoux is the most accurate test to determine the presence of TB.

Pitressin is a hormone replacement medication.

Accidents are the primary source of injury in children and can be life threatening. Appropriate nutrition should have been discussed during the weaning process and while the purchase of appropriate shoes is important, it is not life threatening. One year of age is too early to discuss toilet training.Health Promotion and Maintenance

Chickenpox (varicella) is an acute, infectious, airborne illness that requires others in direct contact to wear a respirator mask.Safety and Infection Control

Family availability to provide care and assistance is not an indicator for skilled home care. In fact, the nurse might see some opportunity for family education in meeting the client’s needs so that less community support is needed. This needs to be negotiated with the family. Frequent hospital readmissions imply that the client has not been able to manage either due to condition instability or lack of care needs being met. This is a red flag for home care services to be able to meet those needs and appropriately monitor the client. A Foley catheter is an indication for home health care due to infection potential and care requirements. IV antibiotics involve home care due to maintaining line patency and assessment of the site.Coordinated Care

Symbols of health or traditions might include certain ritualistic items that are used to maintain, protect, or restore physical, mental, or spiritual health.Psychosocial Integrity

The right to confidentiality of client information might be breached when client care situations are discussed in public areas or without regard to maintaining the information as private and confidential. The other rights listed have not been breached in this instance.Coordinated Care

Hepatitis A is for individuals who travel or persons with chronic liver disease. Infants receive the hepatitis B vaccine at birth. DTaP is administered at 18 months of age. Individuals who come into contact with blood should be immunized against hepatitis B.Health Promotion and Maintenance

Even before the physical assessment (which might or might not be indicated at the time of administration of Vancomycin), ensuring that the client is not allergic to the medication is the most critical action the nurse must take before administering any drug. Lab values regarding renal functioning and therapeutic ranges via peaks and troughs are also important with some medications such as Vancomycin because renal damage can occur if blood drug levels remain high over time.Safety and Infection Control

Structure standards define all the conditions needed to operate, direct, and control a system. They do not address client care but rather describe structure with regard to purpose, such as philosophy, objectives, goals, hours of operation, and management responsibility.Coordinated Care

Choice 3 is indicative of a tension pneumothorax, which is considered a medical emergency. The respiratory system is severely compromised and venous return to the heart is affected. The mediastinal shift is to the unaffected side. Choice 1 contains symptoms of pleurisy, and Choice 2 lists symptoms of bronchitis. Neither are emergencies. The client in Choice 4 should expect difficulty breathing after exercise when asthma is an existing condition and might need immediate attention if his rescue inhaler is ineffective.Physiological Adaptation

The thiazide class of diuretics cause metabolic abnormalities such as elevated blood glucose levels. This elevation is caused in part by diuretic-induced potassium deficiency. Hypokalemia reduces the secretion of insulin by pancreatic beta cells, thereby increasing plasma glucose levels. Thiazides have been used for many years in clients with the conditions described in choices 1 and 2. Thiazides decrease calcium excretion, thus decreasing the likelihood of renal calculi.Pharmacological Therapies

Gagging during the gag reflex test indicates that cranial nerves IX and X (the glossopharyngeal and vagus nerves) are intact.Health Promotion and Maintenance

To protect the confidentiality of the information being reported, the nurse should make the charge nurse on

the unit aware of the situation so that the information can be communicated in an appropriate way in privacy.

Coordinated Care

Monitoring an intravenous infusion must be performed by an RN or LPN. Assisting during activity, offering fluids and recording intake are in the job scope of the nursing assistant.Coordinated Care

The three major sequential maturational crises affecting females are puberty, pregnancy, and menopause. These are life events that have been studied by many researchers and are considered the major events in a woman’s life. Puberty is the onset menarche. Pregnancy is a turning point in one’s life from which there is no return. Menopause is the cessation of menses. The nurse has the responsibility to assess, plan, implement appropriate concepts to facilitate effective functioning, and enhance growth and development. Choices 2, 3, and 4 are not sequential maturational crises.Psychosocial Integrity

Affinity is a close relationship, mutual attraction, or similarity. The tendency of a drug to combine with its receptor is called affinity. Affinity is a measure of the strength of the drug-receptor bonding. Choices 1 and 2 describe the capability of a drug to produce the desired effect. Choice 3 is the branch of science that deals with the effects of forces on the motions of material bodies or with changes in a physical or chemical system.Pharmacological Therapies

Restating allows the client to validate the nurse’s understanding of what has been communicated. It’s an active listening technique. Regarding Choice 2, judgments should be suspended in a nurse-client relationship. Choice 3 is incorrect because leading questions ask for more information rather than showing understanding. Choice 4 communicates understanding, but the client has no way of measuring the understanding.PsychosocialIntegrity

Microorganisms that infect CVADs are often coagulase-negative staphylococci, which can be eliminated by antibiotic administration through the catheter. If unsuccessful in eliminating the microorganism, the CVAD must be removed. CVAD use lessens the need for peripheral IV lines and thus the risk of infiltration. In this case, however, the antibiotics are given to eradicate microorganisms from the CVAD. CVAD use has the effect described in Choice 2, but in this case, the antibiotics are given through the CVAD to eliminate the infective agent. The route does not prevent an allergic reaction.Pharmacological Therapies

Diffusion and absorption depend on the chemical properties of the anesthetic and other factors such as local pH and blood flow. Duration might or might not be longer than general anesthesia. Duration can be short if the type of local anesthetic is a short-acting agent. Client weight is not a factor.Pharmacological Therapies