NCLEX PN Review 21-30

Passing the NCLEX PN Review is a step toward a fulfilling career in the field of nursing.

21. The 57-year-old male client has elected to have epidural anesthesia as the anesthetic during a hernia repair. If the client experiences hypotension, the nurse would:

A. Place him in the Trendelenburg position
B. Obtain an order for Benedryl
C. Administer oxygen per nasal cannula
D. Speed the IV infusion of normal saline

22. A client has cancer of the pancreas. The nurse should be most concerned with which nursing diagnosis?

A. Alteration in nutrition
B. Alteration in bowel elimination
C. Alteration in skin integrity
D. Ineffective individual coping

23. NCLEX PN Review about the nurse who is caring for a client with ascites. Which is the best method to use for determining early ascites?

A. Inspection of the abdomen for enlargement
B. Bimanual palpation for hepatomegaly
C. Daily measurement of abdominal girth
D. Assessment for a fluid wave

24. The client arrives in the emergency department after a motor vehicle accident. Nursing assessment findings include BP 80/34, pulse rate 120, and respirations 20. Which is the client’s most appropriate priority nursing diagnosis?

A. Alteration in cerebral tissue perfusion
B. Fluid volume deficit
C. Ineffective airway clearance
D. Alteration in sensory perception

25. Which information obtained from the visit to a client with hemophilia would cause the most concern? The client:

A. Likes to play football
B. Drinks several carbonated drinks per day
C. Has two sisters with sickle cell tract
D. Is taking acetaminophen to control pain

26. NCLEX PN Review about the nurse on oncology who is caring for a client with a white blood count of 800, a platelet count of 150,000, and a red blood cell count of 250,000. During evening visitation, a visitor is noted to be coughing and sneezing. What action should the nurse take?

A. Ask the visitor to wash his hands
B. Document the visitor’s condition in the chart
C. Ask the visitor to leave and not return until the client’s white blood cell count is 1,000
D. Provide the visitor with a mask and gown

27. The nurse is caring for the client admitted after trauma to the neck in an automobile accident. The client suddenly becomes unresponsive and pale, with a BP of 60 systolic. The initial nurse’s action should be to:

A. Place the client in Trendelenburg position
B. Increase the infusion of normal saline
C. Administer atropine IM
D. Obtain a crash cart

28. Immediately following the removal of a chest tube, the nurse would:

A. Order a chest x-ray
B. Take the blood pressure
C. Cover the insertion site with a Vaseline gauze
D. Ask the client to perform the Valsalva maneuver

29. A client being treated with sodium warfarin has an INR of 9.0. Which intervention would be most important to include in the nursing care plan?

A. Assess for signs of abnormal bleeding
B. Anticipate an increase in the dosage
C. Instruct the client regarding the drug therapy
D. Increase the frequency of neurological assessments

30. Which snack selection by a client with osteoporosis indicates that the client understands the dietary management of the disease?

A. A glass of orange juice
B. A blueberry muffin
C. A cup of yogurt
D. A banana

NCLEX PN Review Answers

21) D
- If the client experiences hypotension after an injection of epidural anesthetic, the nurse should turn him to the left side if possible, apply oxygen by mask, and speed the IV infusion. Epinephrine, not Benedryl, in answer B, should be kept for emergency administration. A is incorrect because placing the client in Trendelenburg position (head down) will allow the anesthesia to move up above the respiratory center, thereby decreasing the diaphragm’s ability to move up and down, ventilating the client. Answer C is incorrect because the oxygen should be applied by mask, not cannula.

22) A
- Cancer of the pancreas frequently leads to severe nausea and vomiting. Answers B, C, and D are incorrect because although they are a concern to the client, they are not the priority nursing diagnosis.

23) C
- NCLEX PN Review Rationale: Measuring the girth daily with a paper tape measure and marking the area that is measured is the most objective method of estimating ascites. Inspection, in answer A, and checking for fluid waves, in answer D, are more subjective and not correct. Palpation of the liver will not tell the amount of ascites, so answer B is incorrect.

24) B
- The vital signs indicate hypovolemic shock, so checking for fluid volume deficit is the appropriate action. Answers A, C, and D do not indicate cerebral tissue perfusion, airway clearance, or sensory perception alterations, and are incorrect.

25) A
- The client with hemophilia is likely to experience bleeding episodes if he participates in contact sports. Drinking several carbonated drinks per day, as in answer B, has no bearing on the hemophiliac’s condition. Having two sisters with sickle cell, as in answer C, is not information that would cause concern. Taking acetaminophen for pain, as in answer D, is an accepted practice and does not cause concern.

26) D
- NCLEX PN Review Rationale: The client with neutropenia should not have visitors with any type of infection, so the best action by the nurse is to give the visitor a mask and a gown. Asking the visitor to wash his hands is good but will not help prevent the infection from spreading by droplets; therefore, answer A is incorrect. Answer B is incorrect because documenting the visitor’s condition is not enough action for the nurse to take. Answer C is incorrect because asking the visitor to leave and not return until the client’s white blood cell count is 1,000 is an insuffient intervention. The normal WBC is 5,000–10,000, so a WBC of 1,000 is not high enough to prevent the client from contracting infections.

27) B
- For some clients with trauma to the neck, the answer would be A; however, in this situation, it is incorrect because lowering the head of the bed could further interfere with the airway. Increasing the infusion and placing the client in supine position is better. If atropine is administered to the client, it should be given IV, not IM, and there is no need for this action at present, as stated in answer C. Answer D is not necessary at this time.

28) C
- When a chest tube is removed, the hole should be immediately covered with a Vaseline gauze to prevent air from rushing into the chest and causing the lung to collapse. The doctor, not the nurse, will order a chest x-ray; therefore, answer A is incorrect. Taking the BP in answer B is good but is not the priority action. Answer D is incorrect because the Valsalva maneuver is done during removal of the tube, not afterward.

29) A
- The normal international normalizing ratio (INR) is 2–3. A 9 might indicate spontaneous bleeding. Answer B is an incorrect action at this time. Answer C is incorrect because just instructing the client regarding his medication is not enough. Answer D is incorrect because increasing the frequency of neurological assessment will not prevent bleeding caused by the prolonged INR.

30) C
- The food with the most calcium is the yogurt. The others are good choices, but not as good as the yogurt, which has approximately 400mg of calcium. Therefore, answers A, B, and D are incorrect.

After you reviewed your answers through its rationale, you can also go back to the first page to start from the beginning:

NCLEX PN Review 1-10

Or proceed to the next set of questions:

NCLEX PN Review 31-40