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Saunders NCLEX-PN Comprehensive exam Questions With Complete Solutions
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Saunders NCLEX-PN Comprehensive exam QuestionsWith Complete Solutions
741. The nurse reinforces home care instructions to the parents
of a child hospitalized with pertussis. The child is in the
convalescent stage and is being prepared for discharge. Which
statement by the parents indicates a need for further teaching?
1. "We need to encourage adequate fluid intake."
2. "Coughing spells may be triggered by dust or smoke."
3. "We need to maintain respiratory precautions and a quiet
environment for at least 2 weeks."
4. "Good hand-washing techniques need to be instituted to
prevent spreading the disease to others." Correct Answers 741.
3
Rationale: Pertussis is transmitted by direct contact or
respiratory droplets from coughing. The communicable period
occurs primarily during the catarrhal stage. Respiratory
precautions are not required during the convalescent phase.
Options 1, 2, and 4 are components of home care instructions.
Test-Taking Strategy: Note the strategic words, need for further
teaching. These words indicate a negative event query and the
need to select the incorrect statement. Options 1 and 4 can be
easily eliminated because they are general interventions
,associated with convalescence. Knowing that coughing spells
are associated with pertussis will assist in directing you to the
correct option from the remaining options. In addition, a 2-week
period of respiratory precautions is not required. Review: home
care instructions for the child with pertussis.
Level of Cognitive Ability: Evaluating
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Evaluation
Content Area: Child Health: Infectious and Communicable
Diseases
Priority Concepts: Gas Exchange, Infection
Reference(s): Hockenberry, Wilson (2013), pp. 428, 653-654.
742. A client enters the emergency department confused,
twitching, and having seizures. His family states he recently was
placed on corticosteroids for arthritis and was feeling better and
exercising daily. Upon assessment, he has flushed skin, dry
mucous membranes, an elevated temperature, and poor skin
turgor. His serum sodium level is 172 mEq/L. Which
interventions would the health care provider likely prescribe?
Select all that apply.
1. Monitor the vital signs.
2. Monitor intake and output.
,3. Increase water intake orally.
4. Monitor the electrolyte levels.
5. Provide a sodium-reduced diet.
6. Administer sodium replacements. Correct Answers 742. 1,
2, 3, 4, 5
Rationale: Hypernatremia is described as having a serum sodium
level that exceeds 145 mEq/L. Signs and symptoms would
include dry mucous membranes, loss of skin turgor, thirst,
flushed skin, elevated temperature, oliguria, muscle twitching,
fatigue, confusion, and seizures. Interventions include
monitoring fluid balance, monitoring vital signs, reducing
dietary intake of sodium, monitoring electrolyte levels, and
increasing oral intake of water. Sodium replacement therapy
would not be prescribed for a client with hypernatremia.
Test-Taking Strategy: Focus on the subject, a sodium level of
172 mEq/L. Knowledge that this level is elevated and
knowledge of the treatment for hyperkalemia will direct you to
the correct options. Review: hypernatremia.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Planning
Content Area: Fundamental Skills: Fluids & Electrolytes
, Priority Concepts: Clinical Judgment, Fluid and Electrolyte
Balance
Reference(s): deWit, Kumagai (2013), pp. 41-42.
743. The nurse is monitoring a client receiving glipizide
(Glucotrol). Which outcome indicates an ineffective response
from the medication?
1. A decrease in polyuria
2. A decrease in polyphagia
3. A fasting plasma glucose of 100 mg/dL
4. A glycosylated hemoglobin level of 12% Correct Answers
743. 4
Rationale: Glipizide (Glucotrol) is an oral hypoglycemic agent
administered to decrease the serum glucose level and the signs
and symptoms of hyperglycemia. Therefore, a decrease in both
polyuria and polyphagia would indicate a therapeutic response.
Laboratory values are also used to monitor a client's response to
treatment. A fasting blood glucose level of 100 mg/dL is within
normal limits. However, glycosylated hemoglobin of 12%
indicates poor glycemic control.
Test-Taking Strategy: Focus on the subject, an ineffective
response to the medication. Recalling that glipizide is an oral
hypoglycemic agent tells you to look for an option that would
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