NCLEX PN Mastery Reviews 101-110

NCLEX PN Mastery Reviews will help you pass the most important test of your career: the NCLEX.

 101. A papular lesion is noted on the perineum of the laboring client. Which initial action is most appropriate?

A. Document the finding
B. Report the finding to the doctor
C. Prepare the client for a C-section
D. Continue primary care as prescribed

102. A client with a diagnosis of human papillomavirus (HPV) is at risk for which of the following?
A. Lymphoma
B. Cervical and vaginal cancer
C. Leukemia
D. Systemic lupus

103. NCLEX PN Mastery Reviews about the client seen in the family planning clinic tells the nurse that she has a painful lesion on the perineum. The nurse is aware that the most likely source of the lesion is:

A. Syphilis
B. Herpes
C. Candidiasis
D. Condylomata

104. A client visiting a family planning clinic is suspected of having an STI. The most diagnostic test for treponema pallidum is:

A. Venereal Disease Research Lab (VDRL)
B. Rapid plasma reagin (RPR)
C. Florescent treponemal antibody (FTA)
D. Thayer-Martin culture (TMC)

105. Which laboratory finding is associated with HELLP syndrome in the obstetric client?

A. Elevated blood glucose
B. Elevated platelet count
C. Elevated creatinine clearance
D. Elevated hepatic enzymes

106. NCLEX PN Mastery Reviews about the nurse who is assessing the deep tendon reflexes of the client with hypomagnesemia. Which method is used to elicit the biceps reflex?

A. The nurse places her thumb on the muscle inset in the antecubital space and taps the thumb briskly with the reflex hammer.
B. The nurse loosely suspends the client’s arm in an open hand while tapping the back of the client’s elbow.
C. The nurse instructs the client to dangle her legs as the nurse strikes the area below the patella with the blunt side of the reflex hammer.
D. The nurse instructs the client to place her arms loosely at her side as the nurse strikes the muscle insert just above the wrist.

107. Which medication should be used with caution in the obstetric client with diabetes?

A. Magnesium sulfate
B. Brethine
C. Stadol
D. Ancef

108. A multigravida is scheduled for an amniocentesis at 32 weeks gestation to determine the L/ S ratio and phosphatidyl glycerol level. The L/ S ratio is 1: 1. The nurse’s assessment of this data is:

A. The infant is at low risk for congenital anomalies.
B. The infant is at high risk for intrauterine growth retardation.
C. The infant is at high risk for respiratory distress syndrome.
D. The infant is at high risk for birth trauma.

109. Which observation in the newborn of a mother who is alcohol dependent would require immediate nursing intervention?

A. Crying
B. Wakefulness
C. Jitteriness
D. Yawning

110. The nurse caring for a client receiving magnesium sulfate must closely observe for side effects associated with drug therapy. An expected side effect of magnesium sulfate is:

A. Decreased urinary output
B. Hypersomnolence
C. Absence of knee jerk reflex
D. Decreased respiratory rate

Answers to NCLEX PN Mastery Reviews

101 ) B
- Any lesion should be reported to the doctor. This can indicate a herpes lesion. Clients with open lesions related to herpes are delivered by Cesarean section because there is a possibility of transmission of the infection to the fetus with direct contact to lesions. It is not enough to document the finding, so answer A is incorrect. The physician must make the decision to perform a C-section, making answer C incorrect. It is not enough to continue primary care, so answer D is incorrect.

102) B
- The client with HPV is at higher risk for cervical and vaginal cancer related to this STI. She is not at higher risk for the other cancers mentioned in answers A, C, and D, so those are incorrect.

103) B
- A lesion that is painful is most likely a herpetic lesion. A chancre lesion associated with syphilis is not painful, so answer A is incorrect. In answer C, candidiasis is a yeast infection and does not present with a lesion, but it is exhibited by a white, cheesy discharge. Condylomata lesions are painless warts, so answer D is incorrect.

104) C
- NCLEX PN Mastery Reviews Rationale: FTA is the only answer choice for treponema pallidum. Answers A and B are incorrect because VDRL and RPR are screening tests for syphilis but are not conclusive of the disease; they only indicate exposure to the disease. The Thayer-Martin culture is a test for gonorrhea, so answer D is incorrect.

105) D
- The criteria for HELLP is hemolysis, elevated liver enzymes, and low platelet count. In answer A, an elevated blood glucose level is not associated with HELLP. Platelets are decreased in HELLP syndrome, not elevated, as stated in answer B. The creatinine levels are elevated in renal disease and are not associated with HELLP syndrome, as stated in answer C.

106) A
- The answer can only be A becausethe other methods elicit different reflexes. Answer B elicits the triceps reflex, answer C elicits the patella reflex, and answer D elicits the radial nerve.

107) B
- Brethine is used cautiously because it raises the blood glucose levels. Answers A, C, and D are all medications that are commonly used in the diabetic client, so there is no need to question the order for these medications.

108) C
- When the L/ S ratio reaches 2: 1, the lungs are considered to be mature. The infant will most likely be small for gestational age and will not be at risk for birth trauma, so answer B is incorrect. The L/ S ratio does not indicate congenital anomalies, as stated in answer A, and the infant is not at risk for intrauterine growth retardation, as stated in answer D.

109) C
- Jitteriness is a sign of seizure in the neonate. Answers A, B, and D are incorrect because crying, wakefulness, and yawning are expected in the newborn.

110) B
- The client is expected to become sleepy, have hot flashes, and experience lethargy. A decreasing urinary output, absence of the knee jerk reflex, and decreased respirations are signs of toxicity and are not expected side effects of magnesium sulfate. Therefore, answers A, C, and D are incorrect.

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NCLEX PN Mastery Reviews 111-120

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Best NCLEX PN Review 91-100

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 91. The nurse is doing bowel and bladder retraining for the client with paraplegia. Which of the following is not a factor for the nurse to consider?

A. Dietary patterns
B. Mobility
C. Fluid intake
D. Sexual function

92. The client returns to the recovery room following repair of an intrathoracic aneurysm. Which finding would require further investigation?

A. Pedal pulses bounding and regular
B. Urinary output 20mL in the past hour
C. Blood pressure 108/ 50
D. Oxygen saturation 97%

93. The nurse is teaching the client regarding use of sodium warfarin. Which statement made by the client would require further teaching?

A. “I will have blood drawn every month.”
B. “I will assess my skin for a rash.”
C. “I take aspirin for a headache.”
D. “I will use an electric razor to shave.”

94. Best NCLEX PN Review about a client  to a semiprivate room. The most suitable roommate for this client is the client with:

A. Hypothyroidism
B. Diabetic ulcers
C. Ulcerative colitis
D. Pneumonia

95. The nurse has just received shift report and is preparing to make rounds. Which client should be seen first?

A. The client who has a history of a cerebral aneurysm with an oxygen saturation rate of 99%
B. The client who is three days post–coronary artery bypass graft with a temperature of 100.2 ° F
C. The client who was admitted 1 hour ago with shortness of breath
D. The client who is being prepared for discharge following a femoral popliteal bypass graft

96. The doctor has ordered antithrombolic stockings to be applied to the legs of the client with peripheral vascular disease. The nurse knows that the proper method of applying the stockings is:

A. Before rising in the morning
B. With the client in a standing position
C. After bathing and applying powder
D. Before retiring in the evening

97. Best NCLEX PN Review about the nurse who is preparing a client with an axillo-popliteal bypass graft for discharge. The client should be taught to avoid:

A. Using a recliner to rest
B. Resting in supine position
C. Sitting in a straight chair
D. Sleeping in right Sim’s position

98. While caring for a client with hypertension, the nurse notes the following vital signs: BP of 140/ 20, pulse 120, respirations 36, temperature 100.8 ° F. The nurse’s initial action should be to:

A. Call the doctor
B. Recheck the vital signs
C. Obtain arterial blood gases
D. Obtain an ECG

99. The nurse is caring for a client with peripheral vascular disease. To correctly assess the oxygen saturation level, the monitor may be placed on the:

A. Abdomen
B. Ankle
C. Earlobe
D. Chin

100. Dalteparin (Fragmin) has been ordered for a client with pulmonary embolis. Which statement made by the graduate nurse indicates inadequate understanding of the medication?

A. “I will administer the medication before meals.”
B. “I will administer the medication in the abdomen.”
C. “I will check the PTT before administering the medication.”
D. “I will not need to aspirate when I give Dalteparin.”

Best NCLEX PN Review

91) D
- When assisting the client with bowel and bladder training, the least helpful factor is the sexual function. Dietary history, mobility, and fluid intake are important factors; these must be taken into consideration because they relate to constipation, urinary function, and the ability to use the urinal or bedpan. Therefore, answers A, B, and C are incorrect.

92) B
- Because the aorta is clamped during surgery, the blood supply to the kidneys is impaired. This can result in renal damage. A urinary output of 20mL is oliguria. In answer A, the pedal pulses that are thready and regular are within normal limits. For answer C, it is desirable for the client’s blood pressure to be slightly low after surgical repair of an aneurysm. The oxygen saturation of 97% in answer D is within normal limits and, therefore, incorrect.

93) C
- Best NCLEX PN Review Rationale: The client taking an anticoagulant should not take aspirin because it will further thin the blood. He should return to have a Protime drawn for bleeding time, report a rash, and use an electric razor. Therefore, answers A, B, and D are incorrect. 

94) A
- The best roommate for the post-surgical client is the client with hypothyroidism. This client is sleepy and has no infectious process. Answers B, C, and D are incorrect because the client with a diabetic ulcer, ulcerative colitis, or pneumonia can transmit infection to the post-surgical client. 

95) C
- The client admitted 1 hour ago with shortness of breath should be seen first because this client might require oxygen therapy. The client in answer A with a low-grade temperature can be assessed after the client with shortness of breath. The client in answer B can also be seen later. This client will have some inflammatory process after surgery, so a temperature of 100.2 ° F is not unusual. The low-grade temperature should be re-evaluated in 1 hour. The client in answer D can be reserved for later. 

96) A
- The best time to apply antithrombolytic stockings is in the morning before rising. If the doctor orders them later in the day, the client should return to bed, wait 30 minutes, and apply the stockings. Answers B, C, and D are incorrect because there is likely to be more peripheral edema if the client is standing or has just taken a bath; before retiring in the evening is wrong because, late in the evening, more peripheral edema will be present. 

97) C
- Best NCLEX PN Review Rationale: The client with a femoral popliteal bypass graft should avoid activities that can occlude the femoral artery graft. Sitting in the straight chair and wearing tight clothes are prohibited for this reason. Resting in a supine position, resting in a recliner, or sleeping in right Sim’s are allowed, as stated in answers A, B, and D.

98) A
- The client is exhibiting a widened pulse pressure, tachycardia, and tachypnea. The next action after obtaining these vital signs is to notify the doctor for additional orders. Rechecking the vital signs, as in answer B, is wasting time. It is the doctor’s call to order arterial blood gases and an ECG. 

99) C
- If the finger cannot be used, the next best place to apply the oxygen monitor is to the earlobe. It can also be placed on the forehead, but the choices in answers A, B, and D are incorrect.

100) C
- Giving the medication in the abdomen provides for the best absorption. A is incorrect because there is no need to give this medication prior to meals. B is incorrect because checking the glucose level is unnecessary. D is incorrect because the nurse should not aspirate when administering any heparin derivative subcutaneously.

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Best NCLEX PN Review 101-110

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Best NCLEX PN Review 81-90

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81. The 84-year-old male has returned from the recovery room following a total hip repair. He complains of pain and is medicated by morphine sulfate and promethazine. Which medication should be kept available for the client being treated with opoid analgesics?

A. Nalozone (Narcan)
B. Ketorolac (Toradol)
C. Acetylsalicylic acid (aspirin)
D. Atropine sulfate (Atropine)

82. The nurse is taking the vital signs of the client admitted with cancer of the pancreas. The nurse is aware that the fifth vital sign is:

A. Anorexia
B. Pain
C. Insomnia
D. Fatigue

83. The client with AIDS tells the nurse that he has been using acupuncture to help with his pain. The nurse should question the client regarding this treatment because acupuncture:

A. Uses pressure from the fingers and hands to stimulate the energy points in the body
B. Uses oils extracted from plants and herbs
C. Uses needles to stimulate certain points on the body to treat pain
D. Uses manipulation of the skeletal muscles to relieve stress and pain

84. Best NCLEX PN Review about the client who has an order for heparin to prevent post-surgical thrombi. Immediately following a heparin injection, the nurse should:

A. Aspirate for blood
B. Check the pulse rate
C. Massage the site
D. Check the site for bleeding

85. Which of the following lab studies should be done periodically if the client is taking sodium warfarin (Coumadin)?

A. Stool specimen for occult blood
B. White blood cell count
C. Blood glucose
D. Erthyrocyte count

86. The doctor has ordered 80mg of furosemide (Lasix) two times per day. The nurse notes the patient’s potassium level to be 2.5meq/ L. The nurse should:

A. Administer the Lasix as ordered
B. Administer half the dose
C. Offer the patient a potassium-rich food
D. Withhold the drug and call the doctor

87. The doctor is preparing to remove chest tubes from the client’s left chest. In preparation for the removal, the nurse should instruct the client to:

A. Breathe normally
B. Hold his breath and bear down
C. Take a deep breath
D. Sneeze on command

88. The nurse identifies ventricular tachycardia on the heart monitor. Which action should the nurse prepare to take?

A. Administer atropine sulfate
B. Check the potassium level
C. Administer an antiarrythmic medication such as Lidocaine
D. Defibrillate at 360 joules

89. A client is being monitored using a central venous pressure monitor. If the pressure is 2cm of water, the nurse should:

A. Call the doctor immediately
B. Slow the intravenous infusion
C. Listen to the lungs for rales
D. Administer a diuretic

90. The nurse is evaluating the client’s pulmonary artery pressure. The nurse is aware that this test will evaluate:

A. Pressure in the left ventricle
B. The systolic, diastolic, and mean pressure of the pulmonary artery
C. The pressure in the pulmonary veins
D. The pressure in the right ventricle

Best NCLEX PN Review Answers

81) A
- Narcan is the antidote for the opoid analgesics. Toradol (answer B) is a nonopoid analgesic; aspirin (answer C) is an analgesic, anticoagulant, and antipyretic; and atropine (answer D) is an anticholengergic.

82) B
- The fifth vital sign is pain. Nurses should assess and record pain just as they would temperature, respirations, pulse, and blood pressure. Answers A, C, and D are included in the charting but are not considered to be the fifth vital sign and are, therefore, incorrect.

83) C
- Best NCLEX PN Review Rationale: Acupuncture uses needles, and because HIV is transmitted by blood and body fluids, the nurse should question this treatment. Answer A describes acupressure, and answers B and D describe massage therapy with the use of oils.

84) D
- After administering any subcutaneous anticoagulant, the nurse should check the site for bleeding. Answers A and C are incorrect because aspirating and massaging the site are not done. Checking the pulse is not necessary, as in answer B.

85) A
- An occult blood test should be done periodically to detect any intestinal bleeding on the client with coumadin therapy. Answers B, C, and D are not directly related to the question.

86) D
- Best NCLEX PN Review Rationale: The potassium level of 2.5meq/ L is extremely low. The normal is 3.5–5.5meq/ L. Lasix (furosemide) is a nonpotassium sparing diuretic, so answer A is incorrect. The nurse cannot alter the doctor’s order, as stated in answer B, and answer C will not help with this situation.

87) B
- The client should be asked to perform Valsalva maneuver while the chest tube is being removed. This prevents changes in pressure until an occlusive dressing can be applied. Answers A and C are not recommended, and sneezing is difficult to perform on command.

88) C
- The treatment for ventricular tachycardia is lidocaine. A precordial thump is sometimes successful in slowing the rate, but this should be done only if a defibrillator is available. In answer A, atropine sulfate will speed the rate further; in answer B, checking the potassium is indicated but is not the priority; and in answer D, defibrillation is used for pulseless ventricular tachycardia or ventricular fibrillation. Also, defibrillation should begin at 200 joules and be increased to 360 joules.

89) A
- The normal central venous pressure is 5–10cm of water. A reading of 2cm is low and should be reported. Answers B, C, and D indicate that the nurse believes that the reading is too high and is incorrect.

90) B
- The pulmonary artery pressure will measure the pressure during systole, diastole, and the mean pressure in the pulmonary artery. It will not measure the pressure in the left ventricle, the pressure in the pulmonary veins, or the pressure in the right ventricle. Therefore, answers A, C, and D are incorrect.

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Best NCLEX PN Review 91-100

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NCLEX PN Review 71-80

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71. The nurse is assisting in the care of a patient who is 2 days post-operative from a hemorroidectomy. The nurse would be correct in instructing the patient to:

A. Avoid a high-fiber diet because this can hasten the healing time
B. Continue to use ice packs until discharge and then when at home
C. Take 200mg of Colace bid to prevent constipation
D. Use a sitz bath after each bowel movement to promote cleanliness and comfort

72. NCLEX PN Review about the nurse who is caring for a patient with a colostomy. The patient asks, “Will I ever be able to swim again?” The nurse’s best response would be:

A. “Yes, you should be able to swim again, even with the colostomy.”
B. “You should avoid immersing the colostomy in water.”
C. “No, you should avoid getting the colostomy wet.”
D. “Don’t worry about that. You will be able to live just like you did before.”

73. Which is true regarding the administration of antacids?

A. Antacids should be administered without regard to mealtimes.
B. Antacids should be administered with each meal and snack of the day.
C. Antacids should be administered within 1–2 hours of all other medications.
D. Antacids should be administered with all other medications, for maximal absorption.

74. The nurse is preparing to administer a feeding via a nasogastric tube. The nurse would perform which of the following before initiating the feeding?

A. Assess for tube placement by aspirating stomach content
B. Place the patient in a left-lying position
C. Administer feeding with 50% H20 concentration
D. Ensure that the feeding solution has been warmed in a microwave for 2 minutes

75. The patient is prescribed metronidazole (Flagyl) for adjunct treatment for a duodenal ulcer. When teaching about this medication, the nurse would say:

A. “This medication should be taken only until you begin to feel better.”
B. “This medication should be taken on an empty stomach to increase absorption.
C. “While taking this medication, you do not have to be concerned about being in the sun.”

D. “While taking this medication, alcoholic beverages and products containing alcohol should be avoided.”

76. In planning care for the patient with ulcerative colitis, the nurse identifies which nursing diagnoses as a priority?

A. Anxiety
B. Impaired skin integrity
C. Fluid volume deficit
D. Nutrition altered, less than body requirements

77. NCLEX PN Review about the nurse who is teaching about irritable bowel syndrome (IBS). Which of the following would be most important?

A. Reinforcing the need for a balanced diet
B. Encouraging the client to drink 16 ounces of fluid with each meal
C. Telling the client to eat a diet low in fiber
D. Instructing the client to limit his intake of fruits and vegetables

78. The nurse is planning care for the patient with celiac disease. In teaching about the diet, the nurse should instruct the patient to avoid which of the following for breakfast?

A. Cream of wheat
B. Banana
C. Puffed rice
D. Cornflakes

79. The nurse is caring for a patient with suspected diverticulitis. The nurse would be most prudent in questioning which of the following diagnostic tests ordered?

A. Colonoscopy
B. Barium enema
C. Complete blood count
D. Computed tomography (CT) scan

80. When the nurse is gathering information for the assessment, the patient states, “My stomach hurts about 2 hours after I eat.” Based upon this information, the nurse knows the patient likely has a:

A. Gastric ulcer
B. Duodenal ulcer
C. Peptic ulcer
D. Curling’s ulcer

NCLEX PN Review Answers

71) D
- The use of a sitz bath will help with the pain and swelling associated with a hemorroidectomy. The client should eat foods high in fiber, so answer A is incorrect. Ice packs, as stated in answer B, are ordered immediately after surgery only. Answer C, a stool softener, can be ordered, but only by the doctor.

72) A
- The client with a colostomy can swim and carry on activities as before the colostomy; therefore, answers B and C are incorrect. Answer D shows a lack of empathy.

73) C
- NCLEX PN Review Rationale: Antacids should be administered within 1–2 hours of other medications. If antacids are taken with many medications, they render the other medications inactive. All other answers are incorrect.

74) A
- Before beginning feedings, an x-ray is often obtained to check for placement. Aspirating stomach content and checking the pH for acidity is the best method of checking for placement. Other methods include placing the end in water and checking for bubbling, and injecting air and listening over the epigastric area. Answers B and C are not correct. Answer D is incorrect because warming in the microwave is contraindicated.

75) D
- NCLEX PN Review Rationale: Alcohol will cause extreme nausea if consumed with Flagyl. Answer A is incorrect because the full course of treatment should be taken. The medication should be taken with a full 8oz. of water, with meals, and the client should avoid direct sunlight because he will most likely be photosensitive; therefore, answers A, B, and C are incorrect.

76) C
- Fluid volume deficit can lead to metabolic acidosis and electrolyte loss. The other nursing diagnoses in answers A, B, and D might be applicable but are of lesser priority.

77) A
- The nurse should reinforce the need for a diet balanced in all nutrients and fiber. Foods that often cause diarrhea and bloating associated with irritable bowel syndrome include fried foods, caffeinated beverages, alcohol, and spicy foods. Therefore, answers B, C, and D are incorrect.

78) A
- NCLEX PN Review Rationale: Clients with celiac disease should refrain from eating foods containing gluten. Foods with gluten include wheat barley, oats, and rye. The other foods are allowed.

79) B
- A barium enema is contraindicated in the client with diverticulitis because it can cause bowel perforation. Answers A, C, and D are appropriate diagnostic studies for the client with diverticulitis.

80) B
- Individuals with ulcers within the duodenum typically complain of pain occurring 2–3 hours after a meal, as well as at night. The pain is usually relieved by eating. The pain associated with gastric ulcers, answer A, occurs 30 minutes after eating. Answer C is too vague and does not distinguish the type of ulcer. Answer D is associated with stress.

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NCLEX PN Questions 81-90

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NCLEX PN Prep 61-70

The more NCLEX PN Prep answers you get right, the harder the questions become, until you’ve demonstrated that you’ve mastered the subjects. Check the correct answers below.

61. The client is admitted to the postpartum unit with an order to continue the infusion of Pitocin. Which finding indicates that the Pitocin is having the desired effect?

A. The fundus is deviated to the left.
B. The fundus is firm and in the midline.
C. The fundus is boggy.
D. The fundus is two finger breadths below the umbilicus.

62. The nurse is teaching a group of new graduates about the safety needs of the client receiving chemotherapy. Before administering chemotherapy, the nurse should:

A. Administer a bolus of IV fluid
B. Administer pain medication
C. Administer an antiemetic
D. Allow the patient a chance to eat

63. Before administering Methytrexate orally to the client with cancer, the nurse should check the:

A. IV site
B. Electrolytes
C. Blood gases
D. Vital signs

64. NCLEX PN Prep question about Vitamin K (aquamephyton) that is administered to a newborn shortly after birth for which of the following reasons?

A. To prevent dehydration
B. To treat infection
C. To replace electrolytes
D. To facilitate clotting

65. The client with an ileostomy is being discharged. Which teaching should be included in the plan of care?

A. Use Karaya powder to seal the bag.
B. Irrigate the ileostomy daily.
C. Stomahesive is the best skin protector.
D. Neosporin ointment can be used to protect the skin.

66. The client has an order for FeSo4 liquid. Which method of administration would be best?

A. Administer the medication with milk
B. Administer the medication with a meal
C. Administer the medication with orange juice
D. Administer the medication undiluted

67. The client arrives in the emergency room with a hyphema. Which action by the nurse would be best?

A. Elevate the head of the bed and apply ice to the eye
B. Place the client in a supine position and apply heat to the knee
C. Insert a Foley catheter and measure the intake and output
D. Perform a vaginal exam and check for a discharge

68. NCLEX PN Prep question about the nurse who is making assignments for the day. Which client should be assigned to the nursing assistant?

A. The 18-year-old with a fracture to two cervical vertebrae
B. The infant with meningitis
C. The elderly client with a thyroidectomy 4 days ago
D. The client with a thoracotomy 2 days ago

69. The client arrives in the emergency room with a “bull’s eye” rash. Which question would be most appropriate for the nurse to ask the client?

A. “Have you found any ticks on your body?”
B. “Have you had any nausea in the last 24 hours?”
C. “Have you been outside the country in the last 6 months?”
D. “Have you had any fever for the past few days?”

70. Which of the following is the best indicator of the diagnosis of HIV?

A. White blood cell count
C. Western Blot
D. Complete blood count

NCLEX PN Prep Answers

61) B
- Pitocin is used to cause the uterus to contract and decrease bleeding. A uterus deviated to the left, as stated in answer A, indicates a full bladder. It is not desirable to have a boggy uterus, making answer C incorrect. This lack of muscle tone will increase bleeding. Answer D is incorrect because the position of the uterus is not related to the use of Pitocin.

62) C
- Before chemotherapy, an antiemetic should be given because most chemotherapy agents cause nausea. It is not necessary to give a bolus of IV fluids, medicate for pain, or allow the client to eat; therefore, answers A, B, and D are incorrect. 

63) D
- NCLEX PN Prep Rationale: The vital signs should be taken before any chemotherapy agent. If it is an IV infusion of chemotherapy, the nurse should check the IV site as well. Answers B and C are incorrect because it is not necessary to check the electrolytes or blood gases. 

64) D
- Vitamin K is given after delivery because the newborn’s intestinal tract is sterile and lacks vitamin K needed for clotting. Answer A is incorrect because vitamin K is not directly given to prevent dehydration, but will facilitate clotting. Answers B and C are incorrect because vitamin K does not prevent infection or replace electrolytes.

65) C
- The best protector for the client with an ileostomy to use is stomahesive. Answer A is not correct because the bag will not seal if the client uses Karaya powder. Answer B is incorrect because there is no need to irrigate an ileostomy. Neosporin, answer D, is not used to protect the skin because it is an antibiotic. 

66) C
- NCLEX PN Prep Rationale: FeSO4 or iron should be given with ascorbic acid (vitamin C). This helps with the absorption. It should not be given with meals or milk because this decreases the absorption; thus, answers A and B are incorrect. Giving it undiluted, as stated in answer D, is not good because it tastes bad.

67) A
- Hyphema is blood in the anterior chamber of the eye and around the eye. The client should have the head of the bed elevated and ice applied. Answers B, C, and D are incorrect and do not treat the problem. 

68) C
- The most stable client is the client with the thyroidectomy 4 days ago. Answers A, B, and D are incorrect because the other clients are less stable and require a registered nurse. 

69) A
- The “bull’s eye” rash is indicative of Lyme’s disease, a disease spread by ticks. The signs and symptoms include elevated temperature, headache, nausea, and the rash. Although answers B and D are important, the question asks which would be best. Answer C has no significance. 

70) C
- The most definitive diagnostic tool for HIV is the Western Blot. The white blood cell count, as stated in answer A, is not the best indicator, but a white blood cell count of less than 3,500 requires investigation. The ELISA test, answer B, is a screening exam. Answer D is not specific enough.

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NCLEX PN Prep 71-80

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