NCLEX NCLEX-PN
Best NCLEX Next Gen Prep
1. When a woman is receiving postpartum epidural morphine, the nurse should plan to observe for which of the following side effects to occur within the first 3 hours?
- A. nausea and vomiting
- B. itching
- C. urinary retention
- D. somnolence
Correct answer: itching
Rationale: A side effect of postpartum epidural morphine is the onset of itching within 3 hours of injection and lasting up to 10 hours. Nausea and vomiting might occur 4–7 hours after injection. While urinary retention is a side effect of postpartum epidural morphine, it is not typically assessed within the first 3 hours. Somnolence is a rare side effect and not commonly observed within the first 3 hours. Therefore, itching is the most likely side effect to be observed within the initial 3 hours after administering postpartum epidural morphine.
2. What is the drug of choice for herpes simplex virus 1, herpes simplex virus 2, and varicella-zoster virus?
- A. HIV.
- B. HSV 1, HSV 2, and VZV.
- C. CMV
- D. Influenza A viruses.
Correct answer: HSV 1, HSV 2, and VZV.
Rationale: Acyclovir (Zovirax) is the drug of choice for herpes simplex virus 1 (HSV-1), herpes simplex virus 2 (HSV-2), and varicella-zoster virus (VZV) infections. It works by inhibiting viral DNA replication. Acyclovir is excreted unchanged in the urine, so caution is needed in renal impairment. Choice A, HIV, is incorrect as acyclovir is not the drug of choice for HIV. Choice C, CMV, is incorrect as acyclovir is not the preferred treatment for cytomegalovirus (CMV) infections. Choice D, Influenza A viruses, is incorrect as acyclovir is not used to treat influenza viruses.
3. The nurse is teaching parents of a newborn about feeding their infant. Which of the following instructions should the nurse include?
- A. Use the defrost setting on microwave ovens to warm bottles.
- B. When refrigerating formula, discard partially used bottles after 24 hours.
- C. When using formula concentrate, mix one part concentrate and two parts water.
- D. If a portion of one bottle is left for the next feeding, discard it.
Correct answer: Use the defrost setting on microwave ovens to warm bottles.
Rationale: The correct answer is to use the defrost setting on microwave ovens to warm bottles. It is crucial to be cautious when heating bottles in a microwave to prevent milk from becoming superheated. The defrost setting is recommended, and the formula's temperature should always be checked before feeding the baby. Choice B, which advises to discard partially used bottles of refrigerated formula after 24 hours, is also correct. This is important to prevent the introduction of pathogens by the baby into the formula. Choice C, recommending mixing one part formula concentrate with two parts water, is essential for ensuring the correct dilution. Choice D, suggesting to discard any remaining portion of a bottle for the next feeding, is incorrect. It is not necessary to discard the remaining portion if it has been refrigerated promptly and used within a safe time frame. Adding fresh formula to a partially used bottle is not recommended, as it can lead to the growth of pathogens that may be transferred to the new formula.
4. All of the following are common reasons that nurses are reluctant to delegate except:
- A. lack of self-confidence.
- B. desire to maintain authority.
- C. confidence in subordinates.
- D. getting trapped in the 'I can do it better myself' mindset.
Correct answer: confidence in subordinates.
Rationale: The correct answer is 'confidence in subordinates.' If a delegator has confidence in their subordinates' abilities, they are more likely to delegate tasks. Reasons why nurses are reluctant to delegate include their own lack of self-confidence, the desire to maintain authority, and getting trapped in the 'I can do it better myself' mindset. Therefore, having confidence in subordinates is not a common reason for reluctance to delegate.
5. A nurse is assessing an 18-year-old female who has recently suffered a TBI. The nurse notes a slower pulse and impaired respiration. The nurse should report these findings immediately to the physician due to the possibility the patient is experiencing which of the following conditions?
- A. Increased intracranial pressure
- B. Increased function of cranial nerve X
- C. Sympathetic response to activity
- D. Meningitis
Correct answer: Increased intracranial pressure
Rationale: The nurse should report the slower pulse and impaired respiration to the physician immediately as they are indicative of increased intracranial pressure (ICP) following a traumatic brain injury (TBI). These signs suggest that there may be a rise in pressure within the skull, which can be a life-threatening condition requiring urgent intervention. Options B and C are unlikely in this scenario as they do not correlate with the symptoms presented. Meningitis (Option D) typically presents with different signs and symptoms, such as fever, headache, and neck stiffness, which are not described in the patient's case.
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