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CLEX-PN 3000 QUESTIONS AND ANSWERS WITH RATIONALES.
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CLEX-PN 3000 QUESTIONS AND ANSWERS WITH RATIONALES.
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NCLEX-PN 3000 QUESTIONS AND ANSWERSThe parent of a preschooler with chickenpox asks the nurse about measures to make
the child comfortable. The nurse instructs the parent to avoid administering aspirin or
any other product that contains salicylates. When given to children with chickenpox,
aspirin has been linked to which disorder?
1. Guillain-Barré syndrome
2. Rheumatic fever
3. Reye's syndrome
4. Scarlet fever - answer- Correct Answer: 3
RATIONALES: Research shows a correlation between the use of aspirin during
chickenpox and the development of Reye's syndrome (a disorder characterized by brain
and liver toxicity). Therefore, the nurse should instruct the parents to avoid
administering aspirin or other products that contain salicylates and to consult the
physician or pharmacist before administering any medication to a child with chickenpox.
No research has found a link between aspirin use, chickenpox, and the development of
Guillain-Barré syndrome, rheumatic fever, or scarlet fever.
A client is to have an epidural block to relieve labor pain. The nurse anticipates that the
anesthesiologist will inject the anesthetic agent into the:
1. subarachnoid space.
2. area between the subarachnoid space and the dura mater.
,3. area between the dura mater and the ligamentum flavum.
4. ligamentum flavum. - answer- Correct Answer: 3
RATIONALES: For an epidural block, the nurse should anticipate that the
anesthesiologist will inject a local anesthetic agent into the epidural space, located
between the dura mater and the ligamentum flavum in the lumbar region of the spinal
column. When administering a spinal block, the anesthesiologist injects the anesthetic
agent into the subarachnoid space. The ligamentum flavum and the area between the
subarachnoid space and the dura mater are inappropriate injection sites.
The physician prescribes penicillin potassium oral suspension 56 mg/kg/day in four
divided doses for a client with anorexia nervosa who weighs 25 kg. The medication
dispensed by the pharmacy contains a dosage strength of 125 mg/5 ml. How many
milliliters of solution should the nurse administer with each dose? - answer- Correct
Answer: 14
RATIONALES: To determine the total daily dosage, set up the following proportion:
25 kg/X = 1 kg/56 mg
X = 1,400 mg.
Next, divide the daily dosage by four doses to determine the dose to administer every 6
hours:
X = 1,400 mg/4 doses
X = 350 mg/dose.
The adolescent should receive 350 mg every 6 hours.
Lastly, calculate the volume to give for each dose by setting up this proportion:
X/350 mg = 5 ml/125 mg
X = 14 ml.
Initial client assessment information includes blood pressure 160/110 mm Hg, pulse 88
beats/minute, respiratory rate 22 breaths/minute, and reflexes +3/+4 with 2 beat clonus.
Urine specimen reveals +3 protein, negative sugar and ketones. Based on these
findings, the nurse would expect the client to have which complaints?
1. Headache, blurred vision, and facial and extremity swelling
,2. Abdominal pain, urinary frequency, and pedal edema
3. Diaphoresis, nystagmus, and dizziness
4. Lethargy, chest pain, and shortness of breath - answer- Correct Answer: 1
RATIONALES: The client is exhibiting signs of preeclampsia. In addition to hypertension
and hyperreflexia, most preeclamptic clients have edema. Headache and blurred vision
are indications of the effects of the hypertension. Abdominal pain, urinary frequency,
diaphoresis, nystagmus, dizziness, lethargy, chest pain, and shortness of breath are
inconsistent with a diagnosis of preeclampsia.
The nurse is performing a baseline assessment of a client's skin integrity. Which of the
following is a key assessment parameter?
1. Family history of pressure ulcers
2. Presence of existing pressure ulcers
3. Potential areas of pressure ulcer development
4. Overall risk of developing pressure ulcers - answer- Correct Answer: 4
RATIONALES: When assessing skin integrity, the overall risk potential for developing
pressure ulcers takes priority. Overall risk encompasses existing pressure ulcers as well
as potential areas for development of pressure ulcers. Family history isn't important
when assessing skin integrity.
, The nurse is preparing to boost a client up in bed. She instructs the client to use the
overbed trapeze. Which risk factor for pressure ulcer development is the nurse reducing
by instructing the client to move in this manner?
1. Friction
2. Impaired circulation
3. Localized pressure
4. Shearing forces - answer- Correct Answer: 4
RATIONALES: Using a trapeze reduces shearing forces (opposing forces that cause
layers of skin to move over each other, stretching and tearing capillaries and,
eventually, resulting in necrosis), which increase the risk of pressure ulcer development.
They can occur as clients slide down in bed or when they're pulled up in bed. To reduce
shearing forces, the nurse should instruct the client to use an overbed trapeze, place a
draw sheet under the client to move the client up in bed, and keep the head of the bed
no higher than 30 degrees. The risks of friction, impaired circulation, and localized
pressure aren't decreased with trapeze use.
A geriatric client with Alzheimer's disease has been living with his grown child's family
for the last 6 months. He wanders at night and needs help with activities of daily living.
Which statement by his child suggests that the family is successfully adjusting to this
living arrangement?
1. "It's difficult dealing with Dad. It's a thankless job."
2. "We had no idea this would be so difficult. It's our cross to bear."
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