NCLEX RN PEARSON VUE

1 A client exposed to Mycobacterium tuberculosis

starts on chemoprophylaxis. The nurse provides what

instruction to the client?

Correct answer: 1 To prevent active tuberculosis after exposure, the client is initiated on a single agent regimen,

usually isoniazid (INH). For newly diagnosed active disease (option 2), a combination of

antitubercular agents is used for at least the first several weeks: isoniazid (INH), rifampin

(Rifadin), and pyrazinamide (Tebrazid). The combination therapy lessens the risk of drug

resistance (option 3). Except for streptomycin, which is for IM use, the antitubercular agents

are administered orally (option 4).

The critical words in the stem of the question are exposed and chemoprophylaxis.

Differentiate exposure from infection as the key concept being tested. Recall that if active

infection requires multi‐drug therapy, exposure can be managed with a single agent alone.

1.‐ “You will take a single drug such as isoniazid (INH) by mouth every day for 6 to 12 months.”

2.‐ “You will be on at least two drugs effective against the tubercle bacillus for three months.”

3.‐ “You will be on combination therapy in order to prevent development of drug resistance.”

4.‐ “You will need to learn to give yourself subcutaneous injections.”

2 The nurse delegates an unlicensed assistive person

(UAP) to assist a client with a clean urinary

catheterization procedure. The client had formerly

been able to do the procedure but because of arthritis,

he has been unable to perform the catheterization.

Although the UAP has done this procedure before,

which of the following must the nurse emphasize to

the UAP?

Correct answer: 2 The nurse ensures that the UAP understands the importance of reporting immediately any

difficulties during the procedure such as bleeding. This provides for safe and effective care.

Option 1 is incorrect because the client cannot do the procedure because of arthritis. Option 3

is unnecessary if the UAP is qualified to do the procedure. Option 4 is a function of the nurse,

not the UAP.

The core issue of the question is the appropriate procedure for the nurse to use when

delegating care to a UAP. Eliminate option 4 first because it is the role of the nurse.

Eliminate options 1 and 3 next, because they are not indicated or unnecessary, respectively.

1.‐ Let the client do most of the procedure and report the expected output.

2.‐ Report immediately any unusual observations, such as bleeding.

3.‐ Complete in proper order the steps of the procedure.

4.‐ Perform health teaching while performing the procedure.

3 The client is in the operating room for a surgical

procedure. The nurse in the operating room is

monitoring the physiological integrity of the client.

Which of the following activities is most appropriate?

Correct answer: 4 Only option 4 relates to the client’s physiological integrity. Options 1 and 2 pertain to the

psychological aspects of client care, while option 3 relates to the safety in the environment.

The core issue of the question is knowledge of physiological assessment priorities in the

perioperative client. Fluid loss directly relates to cardiovascular status, which is one of the

ABCs (airway, breathing, and circulation). Use nursing knowledge and the process of

elimination to make a selection.

1.‐ Determine client satisfaction with care received.

2.‐ Assess client’s emotional status.

3.‐ Monitor asepsis in the environment.

4.‐ Calculate fluid loss and its effects.

4 The clinic nurse is conducting health screenings.

Which of the following client assessment findings

indicates that client teaching is needed about the risk

for stroke? Select all that apply.

Correct answer: 1, 2, 4 Obesity, hypertension, and smoking are modifiable risk factors for stroke.

Hypercholesterolemia (cholesterol level greater than 200 mg) would also be a risk factor, but

this client’s level is less than 200 mg/dL. Eating a diet containing fiber helps keep cholesterol

levels low and is not a risk factor for stroke.

The core issue of the question is knowledge of risk factors for stroke. Recall that these are

similar to the risk factors for cardiac disease to help make your selections.

1.‐ Weight 205 lbs and height 5 feet 4 inches

2.‐ Blood pressure 164/92 mmHg

3.‐ Eats bran for breakfast daily

4.‐ Smokes 1/2 pack cigarettes per day

5.‐ Serum cholesterol level is 172 mg/dL

5 Which of the following actions would the nurse take

to maintain medical asepsis when caring for a client

with diabetes mellitus on the medical nursing unit who

requires irrigation of a leg ulcer and insulin injections?

Select all that apply.

Correct answer: 1, 2, 5 Options 1, 2, and 5 are core principles of medical asepsis. Option 3 violates principles of

medical asepsis. Option 4 uses principles of surgical asepsis. Option 6 is unrelated to the needs

of this client.

Use knowledge of medical versus surgical asepsis as essential core concepts. Eliminate

options that utilize surgical asepsis or are unrelated to the needs of the client.

1.‐ Wash hands before and after client care.

2.‐ Wear personal protective equipment during the dressing change.

3.‐ Recap a needle after administering insulin.

4.‐ Change the dressing for a diabetic ulcer using sterile gloves.

5.‐ Wipe the rubber stopper on the insulin vial before withdrawing dose.

6 Laboratory test results indicate a client is in the nadir

period that follows administration of a chemotherapy

drug. Which drug should the nurse avoid administering

to this client at this time?

Correct answer: 2 Red blood cells, white blood cells, and platelet counts may be decreased during the nadir

period following administration of chemotherapy that has hematological toxicity. Medications

that inhibit platelet aggregation should be avoided during the nadir period following

antineoplastic therapy. Aspirin, ibuprofen, and indomethacin are examples of some of these

agents. Tylenol is the drug of choice for mild pain and fever. Benadryl is often used for sinus

drainage or as an antihistamine and Robitussin is used to manage cough.

The core issue of the question is the ability to determine which drugs could increase the

risk of bleeding when a client’s blood counts may be low. Use the process of elimination

and knowledge of drug actions and adverse effects to make a selection.

1.‐ Acetaminophen (Tylenol)

2.‐ Ibuprofen (Motrin)

3.‐ Diphenhydramine (Benadryl)

4.‐ Guanefesin (Robitussin)

7 The newborn nursery has recently formed a unit

policy and procedure committee. The nurse, while

attending and participating in the meetings,

determines that which nurse exemplifies a situational

leader?

Correct answer: 4 A situational leader recognizes that leadership style depends on the readiness and willingness

of the group or the individuals to perform the assigned tasks. The democratic or participative

leader offers suggestions, asks questions, and guides the group toward achieving the group

goals. The laissez‐faire leader recognizes the group’s need for autonomy and abdicates

responsibility. A bureaucratic leader relies on the organization’s rules, policies, and procedures

to direct the group’s work.

The core issue of the question is knowledge of various leadership styles. Use this

knowledge and the process of elimination to make a selection.

1.‐ The nurse who offers suggestions, asks questions, and guides the group toward achieving group goals.

2.‐ The nurse who recognizes the group’s need for autonomy and abdicates responsibility.

3.‐ The nurse who relies on the organization’s rules, policies, and procedures to direct the group’s work.

4.‐ The nurse who recognizes that leadership style depends on the readiness and willingness of the group or the individuals to perform the assigned tasks.

8 The nurse places highest priority on taking which of

the following actions to reduce the spread of

microorganisms when caring for a client at risk for

infection?

Correct answer: 1 Hand hygiene is a core principle of standard precautions. Using gloves is appropriate when

there is a risk of exposure to blood, body fluids, secretions, and excretions. However,

handwashing should be done after removal of gloves. Not all clients require transmission‐

based precautions (option 3) or a private room (option 4).

Use the process of elimination based on nursing knowledge of standard precautions.

Elements of transmission‐based precautions are not initiated with all clients.

1.‐ Wash hands before and after client care.

2.‐ Use clean gloves when implementing client care.

3.‐ Institute transmission‐based precautions.

4.‐ Place the client in a private room.

9 The nurse would report to the physician which of the

following abnormal laboratory values for a 58‐year‐old

client newly admitted to the nursing unit with fever

and diarrhea? Select all that apply.

Correct answer: 1, 4 The white blood cell count is elevated (normal 5,000–10,000/mm<sup>3</sup>),

as is the BUN (0.8–22 mg/dL). These changes would be expected with infection (noted by

fever) and possibly accompanying dehydration from diarrhea. The sodium (135–145 mEq/L),

potassium (3.5–5.1 mEq/L), and serum creatinine (0.8–1.6 mg/dL) are all within normal limits.

The core issue of the question is the ability to discriminate between normal and abnormal

laboratory values. Note the critical symptoms fever and diarrhea, which could lead you to

select elevated white count for infection and elevated BUN with fluid loss from diarrhea.

1.‐ White blood cell count 12,260/mm3

2.‐ Sodium 142 mEq/L

3.‐ Potassium 3.9 mEq/L

4.‐ Blood urea nitrogen 38 mg/dL

5.‐ Serum creatinine 0.9 mg/dL

10 The mental health nurse working with children

anticipates that unrealistic expectations or a sense of

failure to meet standards would cause a 10‐year‐old

child to develop a sense of which of the following?

Correct answer: 3 According to Erikson’s stages of development, a 10‐year‐old child is experiencing industry vs.

inferiority. Shame (option 1), guilt (option 2), and role confusion (option 4) occur at other

developmental levels.

The core issue of the question is the ability to anticipate levels of growth and development

in a 10‐year‐old child. Use knowledge of Erikson’s theory to make a selection

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