NCLEX-PN
Best NCLEX Next Gen Prep
1. 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?
- A. administering immune globulin intravenously
- B. assessing the extremities for edema, redness, and desquamation every 8 hours
- C. explaining progression of the disease to the client and their family
- D. assessing heart sounds and rhythm
Correct answer: C
Rationale: Educating the client and their family about the progression of Kawasaki disease is crucial for promoting a positive body image. By explaining when symptoms are expected to improve and resolve, the client and family can better understand that there will be no permanent disruption in physical appearance that could negatively impact body image. Administering immune globulin intravenously is a treatment for Kawasaki disease but does not directly address body image concerns. Assessing the extremities for edema, redness, and desquamation every 8 hours is important for monitoring the disease but does not directly address body image concerns. Assessing heart sounds and rhythm is essential for evaluating cardiac effects of Kawasaki disease but is not the most direct measure for promoting a positive body image.
2. A client is taking phenelzine (Nardil), and their spouse would like to bring lunch from home. Which of the following is most appropriate for the client to eat?
- A. a banana
- B. grapefruit
- C. a salami sandwich
- D. avocado slices
Correct answer: B
Rationale: The correct answer is grapefruit. Clients taking MAO Inhibitors like phenelzine (Nardil) should avoid foods rich in tyramine to prevent hypertensive crisis. Grapefruit is a suitable choice as it is not high in tyramine. Bananas, avocados, and salami are foods that should be avoided due to their tyramine content, which can interact adversely with MAO Inhibitors. Therefore, choosing grapefruit is the safest option for the client.
3. During a report from an ER nurse about a client, the nurse identifies a statement that requires additional follow-up. Which of the following statements needs further clarification?
- A. "The client said they have been taking aspirin, but I'm not sure for how long or how much."?
- B. "The client frequently takes antacids, but they have not taken any in the last three days."?
- C. "The client stopped taking ibuprofen after developing gastric ulcers."?
- D. "The client takes Antabuse and has stopped using mouthwash."?
Correct answer: A
Rationale: The correct answer requires further follow-up as the nurse needs to know the duration and dosage of aspirin since it can impact the patient's bleeding risk. Choice B does not require immediate follow-up as not taking antacids for three days is not critical. Choice C indicates a necessary decision made by the client to stop ibuprofen after developing gastric ulcers, hence no immediate follow-up is needed. Choice D provides important information, but the priority is to address the lack of specificity regarding the client's aspirin use, which is crucial for assessing bleeding risk and potential interactions.
4. A teenage client is admitted to the hospital because of acetaminophen (Tylenol) overdose. Overdoses of acetaminophen can precipitate life-threatening abnormalities in which of the following organs?
- A. lungs
- B. liver
- C. kidneys
- D. adrenal glands
Correct answer: B
Rationale: Acetaminophen is extensively metabolized in the liver. An overdose of acetaminophen can lead to severe liver damage and even liver failure, which can be life-threatening. Choices A, C, and D are incorrect because although prolonged use of acetaminophen may lead to an increased risk of renal dysfunction, a single overdose does not typically cause life-threatening abnormalities in the lungs, kidneys, or adrenal glands.
5. A client with an ileus is placed on intestinal tube suction. Which of the following electrolytes is lost with intestinal suction?
- A. calcium
- B. magnesium
- C. potassium
- D. sodium chloride
Correct answer: D
Rationale: The correct answer is sodium chloride. Duodenal intestinal fluid is rich in potassium (K+), sodium (Na+), and bicarbonate. When suctioning is used to remove excess fluids due to ileus, it results in the loss of sodium chloride (NaCl) leading to decreased sodium (Na+) levels. Choices A, B, and C are incorrect because calcium, magnesium, and potassium are not typically lost in significant amounts through intestinal tube suction in the context of treating ileus.
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