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NCLEX-PN - National Council Licensure Examination(NCLEX-PN) - BrainDump Information

Vendor Name : NCLEX
Exam Code : NCLEX-PN
Exam Name : National Council Licensure Examination(NCLEX-PN)
Questions and Answers : 723 Q & A
Updated On : April 20, 2018
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Question: 714


The major electrolytes in the extracellular fluid are:

  1. potassium and chloride.

  2. potassium and phosphate.

  3. sodium and chloride.

  4. sodium and phosphate.


Answer: C


Explanation:

Sodium and chloride are the major electrolytes in the extracellular fluid.Physiological Adaptation


Question: 715


A client with Kawasaki disease has bilateral congestion of the conjunctivae, dry cracked lips, a strawberry tongue, and edema of the hands and feet followed by desquamation of fingers and toes. Which of the following nursing measures is most appropriate to meet the expected outcome of positive body image?

  1. administering immune globulin intravenously

  2. assessing the extremities for edema, redness and desquamation every 8 hours

  3. explaining progression of the disease to the client and his or her family

  4. assessing heart sounds and rhythm


Answer: C


Explanation:

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


Question: 716


Which of the following is most likely to impact the body image of an infant newly diagnosed with Hemophilia?

  1. immobility

  2. altered growth and development

  3. hemarthrosis

  4. altered family processes


Answer: D


Explanation:

Altered Family Processes is a potential nursing diagnosis for the family and client with a new diagnosis of Hemophilia. Infants are aware of how their caregivers respond to their needs. Stresses can have an immediate

impact on the infant’s development of trust and how others relate to them because of their diagnosis. The longterm effects of hemophilia can include problems related to immobility. Altered growth and development could not have developed in a newly diagnosed client. Hemarthrosis is acute bleeding into a joint space that is characteristic of hemophilia. It does not have an immediate effect on the body image of a newly diagnosed hemophiliac.Health Promotion and Maintenance


Question: 717


Teaching about the need to avoid foods high in potassium is most important for which client?

  1. a client receiving diuretic therapy

  2. a client with an ileostomy

  3. a client with metabolic alkalosis

  4. a client with renal disease


Answer: D


Explanation:

Clients with renal disease are predisposed to hyperkalemia and should avoid foods high in potassium. Choices 1, 2, and 3 are incorrect because clients receiving diuretics with ileostomy or with metabolic alkalosis are at risk for hypokalemia and should be encouraged to eat foods high in potassium.Physiological Adaptation


Question: 718


What do the following ABG values indicate: pH 7.38, PO2 78 mmHg, PCO2 36mmHg, and HCO3 24 mEq/L?

  1. metabolic alkalosis

  2. homeostasis

  3. respiratory acidosis

  4. respiratory alkalosis


Answer: B


Explanation:

These ABG values are within normal limits. Choices 1, 3, and 4 are incorrect because the ABG values indicate none of these acid-base disturbances.Physiological Adaptation


Question: 719


When administering intravenous electrolyte solution, the nurse should take which of the following precautions?

  1. Infuse hypertonic solutions rapidly.

  2. Mix no more than 80 mEq of potassium per liter of fluid.

  3. Prevent infiltration of calcium, which causes tissue necrosis and sloughing.

  4. As appropriate, reevaluate the client’s digitalis dosage. He might need an increased dosage because IV calcium diminishes digitalis’s action.


Answer: C


Explanation:

Preventing tissue infiltration is important to avoid tissue necrosis. Choice 1 is incorrect because hypertonic solutions should be infused cautiously and checked with the RN if there is a concern. Choice 2 is incorrect because potassium, mixed in the pharmacy per physician order, is mixed at a concentration no higher than 60 mEq/L. Physiological Adaptation


Question: 720


Which of the following physical findings indicates that an 1112-month-old child is at risk for developmental

dysplasia of the hip?

  1. refusal to walk

  2. not pulling to a standing position

  3. negative Trendelenburg sign

  4. negative Ortolani sign


Answer: B


Explanation:

The nurse might be concerned about developmental dysplasia of the hip if an 1112-month-old child doesn’t pull to a standing position. An infant who does not walk by 15 months of age should be evaluated. Children should start walking between 1115 months of age. Trendelenberg sign is related to weakness of the gluteus medius muscle, not hip dysplasia. Ortolani sign is used to identify congenital subluxation or dislocation of the hip in infants.Health Promotion and Maintenance


Question: 721


When obtaining a health history on a menopausal woman, which information should a nurse recognize as a contraindication for hormone replacement therapy?

  1. family history of stroke

  2. ovaries removed before age 45

  3. frequent hot flashes and/or night sweats

  4. unexplained vaginal bleeding


Answer: D


Explanation:

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


Question: 722


Which of the following statements, if made by the parents of a newborn, does not indicate a need for further teaching about cord care?

  1. "I should put alcohol on my baby’s cord 34 times a day."

  2. "I should put the baby’s diaper on so that it covers the cord."

  3. "I should call the physician if the cord becomes dark."

  4. "I should wash my hands before and after I take care of the cord."


Answer: D


Explanation:

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 34 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


Question: 723


The nurse is teaching parents of a newborn about feeding their infant. Which of the following instructions should the nurse include?

  1. Use the defrost setting on microwave ovensto warm bottles.

  2. When refrigerating formula, don’t feed the baby partially used bottles after 24 hours.

  3. When using formula concentrate, mix two parts water and one part concentrate.

  4. If a portion of one bottle is left for the next feeding, go ahead and add new formula to fill it.


Answer: A


Explanation:

Parents must be careful when warming bottles in a microwave oven because the milk can become superheated. When a microwave oven is used, the defrost setting should be chosen, and the temperature of the formula should be checked before giving it to the baby. Refrigerated, partially used bottles should be discarded after 4 hours because the baby might have introduced some pathogens into the formula. Returning the bottle to the refrigerator does not destroy pathogens. Formula concentrate and water are usually mixed in a 1:1 ratio of one part concentrate and one part water. Infants should be offered fresh formula at each feeding. Partially used bottles should not have fresh formula added to them. Pathogens can grow in partially used bottles of formula and be transferred to the new formula.Health Promotion and Maintenance

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