NCLEX-PN Practice Questions

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1). A 60-year-old female patient with a history of chronic obstructive pulmonary disease (COPD) is admitted to the hospital with an acute exacerbation. Which of the following interventions should the nurse prioritize to improve the patient’s oxygenation?
Administering 2 liters of oxygen via nasal cannula
Encouraging pursed-lip breathing exercises
Administering a bronchodilator as prescribed
Placing the patient in a supine position
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Correct Answer:

B. Encouraging pursed-lip breathing exercises

Rationale:

A. Administering 2 liters of oxygen via nasal cannula: While supplemental oxygen may be necessary, it should be carefully titrated in COPD patients to avoid suppressing their drive to breathe. Therefore, it's not always the first or only intervention.
B. Encouraging pursed-lip breathing exercises: Pursed-lip breathing helps to keep the airways open longer, allowing more air to escape and improving ventilation and oxygenation. This technique is beneficial during an acute exacerbation of COPD.
C. Administering a bronchodilator as prescribed: While bronchodilators are essential in managing COPD exacerbations, the immediate intervention to improve oxygenation would be encouraging effective breathing techniques like pursed-lip breathing.
D. Placing the patient in a supine position: This position can worsen dyspnea in COPD patients by limiting lung expansion. Instead, sitting upright or in a semi-Fowler's position is recommended to facilitate better breathing.
References:

National Council of State Boards of Nursing (NCSBN). (2020). NCLEX-PN Examination Candidate Bulletin.
Global Initiative for Chronic Obstructive Lung Disease (GOLD). (2023). Global Strategy for the Diagnosis, Management, and Prevention of COPD.
Lewis, S. M., Bucher, L., Heitkemper, M. M., Harding, M. M., Kwong, J., & Roberts, D. (2017). Medical-Surgical Nursing: Assessment and Management of Clinical Problems. Elsevier.
5
Incorrect Answer:

The correct answer is: Encouraging pursed-lip breathing exercises

Rationale:

A. Administering 2 liters of oxygen via nasal cannula: While supplemental oxygen may be necessary, it should be carefully titrated in COPD patients to avoid suppressing their drive to breathe. Therefore, it's not always the first or only intervention.
B. Encouraging pursed-lip breathing exercises: Pursed-lip breathing helps to keep the airways open longer, allowing more air to escape and improving ventilation and oxygenation. This technique is particularly useful during an acute exacerbation of COPD.
C. Administering a bronchodilator as prescribed: While bronchodilators are essential in managing COPD exacerbations, the immediate intervention to improve oxygenation would be encouraging effective breathing techniques like pursed-lip breathing.
D. Placing the patient in a supine position: This position can worsen dyspnea in COPD patients by limiting lung expansion. Instead, sitting upright or in a semi-Fowler's position is recommended to facilitate better breathing.
References:

National Council of State Boards of Nursing (NCSBN). (2020). NCLEX-PN Examination Candidate Bulletin.
Global Initiative for Chronic Obstructive Lung Disease (GOLD). (2023). Global Strategy for the Diagnosis, Management, and Prevention of COPD.
Lewis, S. M., Bucher, L., Heitkemper, M. M., Harding, M. M., Kwong, J., & Roberts, D. (2017). Medical-Surgical Nursing: Assessment and Management of Clinical Problems. Elsevier.
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2). A 45-year-old male patient with a history of type 2 diabetes mellitus is admitted with cellulitis of the left leg. What is the most important action for the nurse to take to prevent further complications?
Elevate the affected leg
Apply warm compresses to the affected area
Administer prescribed antibiotics
Monitor blood glucose levels closely
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Correct Answer: C. Administer prescribed antibiotics

Rationale:

A. Elevate the affected leg: Elevation can help reduce swelling and improve circulation but is not the most critical intervention to prevent complications in cellulitis.
B. Apply warm compresses to the affected area: Warm compresses can help alleviate pain and promote healing but are not the primary intervention to prevent complications.
C. Administer prescribed antibiotics: Antibiotics are crucial in treating cellulitis, as it is typically caused by bacterial infection. Prompt administration helps prevent the infection from spreading and leading to more severe complications such as sepsis.
D. Monitor blood glucose levels closely: While monitoring blood glucose is important in diabetic patients to prevent hyperglycemia and related complications, it is not the primary intervention to address the infection directly.

References:

National Council of State Boards of Nursing (NCSBN). (2020). NCLEX-PN Examination Candidate Bulletin.
American Diabetes Association. (2023). Standards of Medical Care in Diabetes.
Bickley, L. S. (2017). Bates' Guide to Physical Examination and History Taking. Wolters Kluwer.
8
Incorrect

Correct answer: C. Administer prescribed antibiotics

Rationale:

A. Elevate the affected leg: Elevation can help reduce swelling and improve circulation but is not the most critical intervention to prevent complications in cellulitis.
B. Apply warm compresses to the affected area: Warm compresses can help alleviate pain and promote healing but are not the primary intervention to prevent complications.
C. Administer prescribed antibiotics: Antibiotics are crucial in treating cellulitis, as it is typically caused by bacterial infection. Prompt administration helps prevent the infection from spreading and leading to more severe complications such as sepsis.
D. Monitor blood glucose levels closely: While monitoring blood glucose is important in diabetic patients to prevent hyperglycemia and related complications, it is not the primary intervention to address the infection directly.

References:

National Council of State Boards of Nursing (NCSBN). (2020). NCLEX-PN Examination Candidate Bulletin.
American Diabetes Association. (2023). Standards of Medical Care in Diabetes.
Bickley, L. S. (2017). Bates' Guide to Physical Examination and History Taking. Wolters Kluwer.
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3). A patient receives heparin therapy for a deep vein thrombosis (DVT). Which laboratory test result should the nurse monitor to evaluate the effectiveness of the heparin?
Prothrombin time (PT)
Activated partial thromboplastin time (aPTT)
Platelet count
Hematocrit
10
Correct Answer: C. Activated partial thromboplastin time (aPTT)

Rationale:

A. Prothrombin time (PT): PT is used to monitor warfarin therapy, not heparin.
B. Platelet count: Platelet count is important for assessing bleeding risk but does not directly measure the effectiveness of heparin therapy.
C. Activated partial thromboplastin time (aPTT): aPTT is the correct test to monitor heparin therapy as it measures the time it takes for blood to clot, which is affected by heparin.
D. Hematocrit: Hematocrit measures the proportion of red blood cells in the blood and is not used to monitor heparin therapy.

References:

National Council of State Boards of Nursing (NCSBN). (2020). NCLEX-PN Examination Candidate Bulletin.
American Heart Association. (2023). Guidelines for Anticoagulation Therapy.
McCance, K. L., & Huether, S. E. (2018). Pathophysiology: The Biologic Basis for Disease in Adults and Children. Elsevier.
11
Incorrect

Correct Answer: C. Activated partial thromboplastin time (aPTT)

Rationale:

A. Prothrombin time (PT): PT is used to monitor warfarin therapy, not heparin.
B. Platelet count: Platelet count is important for assessing bleeding risk but does not directly measure the effectiveness of heparin therapy.
C. Activated partial thromboplastin time (aPTT): aPTT is the correct test to monitor heparin therapy as it measures the time it takes for blood to clot, which is affected by heparin.
D. Hematocrit: Hematocrit measures the proportion of red blood cells in the blood and is not used to monitor heparin therapy.

References:

National Council of State Boards of Nursing (NCSBN). (2020). NCLEX-PN Examination Candidate Bulletin.
American Heart Association. (2023). Guidelines for Anticoagulation Therapy.
McCance, K. L., & Huether, S. E. (2018). Pathophysiology: The Biologic Basis for Disease in Adults and Children. Elsevier.
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4). A patient with heart failure is prescribed furosemide (Lasix). Which electrolyte imbalance should the nurse monitor for in this patient?
Hypercalcemia
Hypokalemia
Hyperkalemia
Hypernatremia
13
Correct Answer: C. Hypokalemia

Rationale:

A. Hypercalcemia: Furosemide does not typically cause hypercalcemia; it may actually lower calcium levels.
B. Hyperkalemia: Furosemide is more likely to cause hypokalemia due to its potassium-wasting effects.
C. Hypokalemia: Furosemide, a loop diuretic, can lead to significant loss of potassium, resulting in hypokalemia.
D. Hypernatremia: Furosemide may lead to hyponatremia rather than hypernatremia due to excessive sodium loss.

References:

National Council of State Boards of Nursing (NCSBN). (2020). NCLEX-PN Examination Candidate Bulletin.
American Heart Association. (2023). Guidelines for the Management of Heart Failure.
Lilley, L. L., Collins, S. R., & Snyder, J. S. (2019). Pharmacology and the Nursing Process. Elsevier.
14
Incorrect

Correct answer: C. Hypokalemia

Rationale:

A. Hypercalcemia: Furosemide does not typically cause hypercalcemia; it may actually lower calcium levels.
B. Hyperkalemia: Furosemide is more likely to cause hypokalemia due to its potassium-wasting effects.
C. Hypokalemia: Furosemide, a loop diuretic, can lead to significant loss of potassium, resulting in hypokalemia.
D. Hypernatremia: Furosemide may lead to hyponatremia rather than hypernatremia due to excessive sodium loss.

References:

National Council of State Boards of Nursing (NCSBN). (2020). NCLEX-PN Examination Candidate Bulletin.
American Heart Association. (2023). Guidelines for the Management of Heart Failure.
Lilley, L. L., Collins, S. R., & Snyder, J. S. (2019). Pharmacology and the Nursing Process. Elsevier.
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5). A 70-year-old male with Parkinson's disease is prescribed carbidopa-levodopa (Sinemet). What is the most important instruction the nurse should provide to the patient regarding this medication?
"Take the medication with a high-protein meal."
"Report any uncontrolled movements such as twitching."
"Expect a rapid improvement in symptoms within a few days."
"Discontinue the medication if you experience dizziness."
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Correct Answer: B. "Report any uncontrolled movements such as twitching."

Rationale:

A. "Take the medication with a high-protein meal.": High-protein meals can interfere with the absorption of carbidopa-levodopa, so it should be taken on an empty stomach or with a low-protein snack.
B. "Report any uncontrolled movements such as twitching.": Uncontrolled movements or dyskinesias are common side effects of carbidopa-levodopa and should be reported to the healthcare provider.
C. "Expect a rapid improvement in symptoms within a few days.": Symptom improvement with carbidopa-levodopa may take several weeks.
D. "Discontinue the medication if you experience dizziness.": Patients should not discontinue the medication without consulting their healthcare provider.
References:

National Council of State Boards of Nursing (NCSBN). (2020). NCLEX-PN Examination Candidate Bulletin.
Parkinson’s Foundation. (2023). Medications for Motor Symptoms.
Jarvis, C. (2019). Physical Examination & Health Assessment. Elsevier.
17

Incorrect

Correct Answer: B. "Report any uncontrolled movements such as twitching."

Rationale:

A. "Take the medication with a high-protein meal.": High-protein meals can interfere with the absorption of carbidopa-levodopa, so it should be taken on an empty stomach or with a low-protein snack.
B. "Report any uncontrolled movements such as twitching.": Uncontrolled movements or dyskinesias are common side effects of carbidopa-levodopa and should be reported to the healthcare provider.
C. "Expect a rapid improvement in symptoms within a few days.": Symptom improvement with carbidopa-levodopa may take several weeks.
D. "Discontinue the medication if you experience dizziness.": Patients should not discontinue the medication without consulting their healthcare provider.
References:

National Council of State Boards of Nursing (NCSBN). (2020). NCLEX-PN Examination Candidate Bulletin.
Parkinson’s Foundation. (2023). Medications for Motor Symptoms.
Jarvis, C. (2019). Physical Examination & Health Assessment. Elsevier.
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6). A 25-year-old female patient is admitted with a diagnosis of acute pyelonephritis. Which of the following symptoms would the nurse expect to find during the assessment?
Flank pain and fever
Hematuria and suprapubic pain
Lower abdominal pain and cloudy urine
Dysuria and urinary frequency
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Correct Answer: A. Flank pain and fever

Rationale:

A. Flank pain and fever: These are classic symptoms of acute pyelonephritis, indicating an upper urinary tract infection.
B. Lower abdominal pain and cloudy urine: These symptoms are more indicative of a lower urinary tract infection, such as cystitis.
C. Hematuria and suprapubic pain: Hematuria can occur with pyelonephritis but is more commonly associated with lower urinary tract infections.
D. Dysuria and urinary frequency: These symptoms are typical of lower urinary tract infections.

References:

National Council of State Boards of Nursing (NCSBN). (2020). NCLEX-PN Examination Candidate Bulletin.
American Urological Association. (2023). Guidelines for the Management of Pyelonephritis.
Porth, C. M. (2018). Pathophysiology: Concepts of Altered Health States. Lippincott Williams & Wilkins.
20
incorrect

Correct Answer: A. Flank pain and fever

Rationale:

A. Flank pain and fever: These are classic symptoms of acute pyelonephritis, indicating an upper urinary tract infection.
B. Lower abdominal pain and cloudy urine: These symptoms are more indicative of a lower urinary tract infection, such as cystitis.
C. Hematuria and suprapubic pain: Hematuria can occur with pyelonephritis but is more commonly associated with lower urinary tract infections.
D. Dysuria and urinary frequency: These symptoms are typical of lower urinary tract infections.

References:

National Council of State Boards of Nursing (NCSBN). (2020). NCLEX-PN Examination Candidate Bulletin.
American Urological Association. (2023). Guidelines for the Management of Pyelonephritis.
Porth, C. M. (2018). Pathophysiology: Concepts of Altered Health States. Lippincott Williams & Wilkins.
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7). A 68-year-old female with a history of osteoporosis is prescribed alendronate (Fosamax). Which instruction should the nurse provide to ensure proper administration of the medication?
"Take the medication with a full glass of water and remain upright for at least 30 minutes."
"Take the medication with milk to enhance absorption."
"Take the medication at bedtime for best results."
"Take the medication with food to avoid gastrointestinal upset."
22
Correct Answer: A. "Take the medication with a full glass of water and remain upright for at least 30 minutes."

Rationale:

A. "Take the medication with a full glass of water and remain upright for at least 30 minutes.": This instruction helps prevent esophageal irritation and enhances absorption.
B. "Take the medication with milk to enhance absorption.": Calcium in milk can interfere with the absorption of alendronate.
C. "Take the medication at bedtime for best results.": Alendronate should not be taken at bedtime as it requires the patient to remain upright for 30 minutes.
D. "Take the medication with food to avoid gastrointestinal upset.": Alendronate should be taken on an empty stomach to ensure proper absorption.

References:

National Council of State Boards of Nursing (NCSBN). (2020). NCLEX-PN Examination Candidate Bulletin.
National Osteoporosis Foundation. (2023). Medication Guide.
Lilley, L. L., Collins, S. R., & Snyder, J. S. (2019). Pharmacology and the Nursing Process. Elsevier.
23
Incorrect

correct Aanswer: A. "Take the medication with a full glass of water and remain upright for at least 30 minutes."

Rationale:

A. "Take the medication with a full glass of water and remain upright for at least 30 minutes.": This instruction helps prevent esophageal irritation and enhances absorption.
B. "Take the medication with milk to enhance absorption.": Calcium in milk can interfere with the absorption of alendronate.
C. "Take the medication at bedtime for best results.": Alendronate should not be taken at bedtime as it requires the patient to remain upright for 30 minutes.
D. "Take the medication with food to avoid gastrointestinal upset.": Alendronate should be taken on an empty stomach to ensure proper absorption.

References:

National Council of State Boards of Nursing (NCSBN). (2020). NCLEX-PN Examination Candidate Bulletin.
National Osteoporosis Foundation. (2023). Medication Guide.
Lilley, L. L., Collins, S. R., & Snyder, J. S. (2019). Pharmacology and the Nursing Process. Elsevier.
24
8). A 30-year-old female presents with symptoms of hyperthyroidism. Which signs would the nurse expect to find during the assessment?
Bradycardia and weight gain
Tachycardia and heat intolerance
Dry skin and cold intolerance
Constipation and hair loss
25
Correct Answer: B. Tachycardia and heat intolerance

Rationale:

A. Bradycardia and weight gain: These symptoms are associated with hypothyroidism, not hyperthyroidism.
B. Tachycardia and heat intolerance: These are common symptoms of hyperthyroidism due to increased metabolic rate.
C. Dry skin and cold intolerance: These symptoms are indicative of hypothyroidism.
D. Constipation and hair loss: These symptoms are also more commonly seen in hypothyroidism.

References:

National Council of State Boards of Nursing (NCSBN). (2020). NCLEX-PN Examination Candidate Bulletin.
American Thyroid Association. (2023). Hyperthyroidism Guidelines.
Jarvis, C. (2019). Physical Examination & Health Assessment. Elsevier.
26
Incorrect

Correct Answer: B. Tachycardia and heat intolerance

Rationale:

A. Bradycardia and weight gain: These symptoms are associated with hypothyroidism, not hyperthyroidism.
B. Tachycardia and heat intolerance: These are common symptoms of hyperthyroidism due to increased metabolic rate.
C. Dry skin and cold intolerance: These symptoms are indicative of hypothyroidism.
D. Constipation and hair loss: These symptoms are also more commonly seen in hypothyroidism.

References:

National Council of State Boards of Nursing (NCSBN). (2020). NCLEX-PN Examination Candidate Bulletin.
American Thyroid Association. (2023). Hyperthyroidism Guidelines.
Jarvis, C. (2019). Physical Examination & Health Assessment. Elsevier.
27
9). A 55-year-old male is diagnosed with chronic kidney disease (CKD). Which of the following dietary modifications should the nurse recommend?
High-protein diet
Low-sodium diet
High-phosphorus diet
High-potassium diet
28
Correct Answer: C. Low-sodium diet

Rationale:

A. High-protein diet: High protein intake can worsen kidney function in CKD patients.
B. High-phosphorus diet: Patients with CKD should avoid high-phosphorus foods to prevent complications.
C. Low-sodium diet: Reducing sodium intake helps control blood pressure and fluid balance, which is crucial in CKD management.
D. High-potassium diet: CKD patients are at risk for hyperkalemia, so high-potassium foods should be limited.

References:

National Council of State Boards of Nursing (NCSBN). (2020). NCLEX-PN Examination Candidate Bulletin.
National Kidney Foundation. (2023). Nutrition and Chronic Kidney Disease.
McCance, K. L., & Huether, S. E. (2018). Pathophysiology: The Biologic Basis for Disease in Adults and Children. Elsevier.
29
Incorrect

Correct Answer: C. Low-sodium diet

Rationale:

A. High-protein diet: High protein intake can worsen kidney function in CKD patients.
B. High-phosphorus diet: Patients with CKD should avoid high-phosphorus foods to prevent complications.
C. Low-sodium diet: Reducing sodium intake helps control blood pressure and fluid balance, which is crucial in CKD management.
D. High-potassium diet: CKD patients are at risk for hyperkalemia, so high-potassium foods should be limited.

References:

National Council of State Boards of Nursing (NCSBN). (2020). NCLEX-PN Examination Candidate Bulletin.
National Kidney Foundation. (2023). Nutrition and Chronic Kidney Disease.
McCance, K. L., & Huether, S. E. (2018). Pathophysiology: The Biologic Basis for Disease in Adults and Children. Elsevier.
30
10). A 40-year-old female patient is being treated for tuberculosis (TB). Which of the following medications is included in the standard treatment regimen for TB?
Metronidazole
Ciprofloxacin
Rifampin
Amoxicillin
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Correct Answer: C. Rifampin

Rationale:

A. Metronidazole: This antibiotic is not used for TB treatment.
B. Ciprofloxacin: This antibiotic is not a first-line treatment for TB.
C. Rifampin: Rifampin is a first-line medication used in the standard treatment regimen for TB.
D. Amoxicillin: This antibiotic is not used for TB treatment.

References:

National Council of State Boards of Nursing (NCSBN). (2020). NCLEX-PN Examination Candidate Bulletin.
Centers for Disease Control and Prevention (CDC). (2023). Tuberculosis (TB) Treatment Guidelines.
Lilley, L. L., Collins, S. R., & Snyder, J. S. (2019). Pharmacology and the Nursing Process. Elsevier.
32
Incorrect

Correct Answer: C. Rifampin

Rationale:

A. Metronidazole: This antibiotic is not used for TB treatment.
B. Ciprofloxacin: This antibiotic is not a first-line treatment for TB.
C. Rifampin: Rifampin is a first-line medication used in the standard treatment regimen for TB.
D. Amoxicillin: This antibiotic is not used for TB treatment.

References:

National Council of State Boards of Nursing (NCSBN). (2020). NCLEX-PN Examination Candidate Bulletin.
Centers for Disease Control and Prevention (CDC). (2023). Tuberculosis (TB) Treatment Guidelines.
Lilley, L. L., Collins, S. R., & Snyder, J. S. (2019). Pharmacology and the Nursing Process. Elsevier.
33
11). A patient with a history of peptic ulcer disease (PUD) presents with sudden severe abdominal pain and a rigid abdomen. What is the most likely complication the nurse should suspect?
Perforation
Gastric outlet obstruction
Gastroesophageal reflux disease (GERD)
Chronic gastritis
34
Correct Answer: A. Perforation

Rationale:

A. Perforation: Sudden severe abdominal pain and a rigid abdomen are classic signs of a perforated peptic ulcer, which is a medical emergency.
B. Gastroesophageal reflux disease (GERD): GERD typically causes heartburn and regurgitation, not acute severe pain and a rigid abdomen.
C. Gastric outlet obstruction: This can cause vomiting and abdominal distension but not sudden severe pain and rigidity.
D. Chronic gastritis: This causes persistent pain and discomfort but not the acute symptoms described.

References:

National Council of State Boards of Nursing (NCSBN). (2020). NCLEX-PN Examination Candidate Bulletin.
American Gastroenterological Association. (2023). Guidelines on Peptic Ulcer Disease.
McCance, K. L., & Huether, S. E. (2018). Pathophysiology: The Biologic Basis for Disease in Adults and Children. Elsevier.
35
Incorrect

Correct Answer: A. Perforation

Rationale:

A. Perforation: Sudden severe abdominal pain and a rigid abdomen are classic signs of a perforated peptic ulcer, which is a medical emergency.
B. Gastroesophageal reflux disease (GERD): GERD typically causes heartburn and regurgitation, not acute severe pain and a rigid abdomen.
C. Gastric outlet obstruction: This can cause vomiting and abdominal distension but not sudden severe pain and rigidity.
D. Chronic gastritis: This causes persistent pain and discomfort but not the acute symptoms described.

References:

National Council of State Boards of Nursing (NCSBN). (2020). NCLEX-PN Examination Candidate Bulletin.
American Gastroenterological Association. (2023). Guidelines on Peptic Ulcer Disease.
McCance, K. L., & Huether, S. E. (2018). Pathophysiology: The Biologic Basis for Disease in Adults and Children. Elsevier.
36
12). A 75-year-old male patient with chronic atrial fibrillation is prescribed warfarin (Coumadin). Which dietary advice should the nurse provide?
"Increase your intake of green leafy vegetables."
"Avoid grapefruit juice."
"Limit your intake of vitamin K-rich foods."
"Take the medication with a high-fat meal."
37
Correct Answer: C. "Limit your intake of vitamin K-rich foods."

Rationale:

A. "Increase your intake of green leafy vegetables.": Green leafy vegetables are high in vitamin K, which can interfere with the anticoagulant effect of warfarin.
B. "Avoid grapefruit juice.": While grapefruit juice can interact with many medications, it does not significantly affect warfarin.
C. "Limit your intake of vitamin K-rich foods.": Vitamin K can counteract the effects of warfarin, so patients should maintain a consistent intake to avoid fluctuations in their INR.
D. "Take the medication with a high-fat meal.": Warfarin absorption is not significantly affected by fat intake.

References:

National Council of State Boards of Nursing (NCSBN). (2020). NCLEX-PN Examination Candidate Bulletin.
American Heart Association. (2023). Warfarin Therapy Guidelines.
Lilley, L. L., Collins, S. R., & Snyder, J. S. (2019). Pharmacology and the Nursing Process. Elsevier.
38
Incorrect

Correct Answer: C. "Limit your intake of vitamin K-rich foods."

Rationale:

A. "Increase your intake of green leafy vegetables.": Green leafy vegetables are high in vitamin K, which can interfere with the anticoagulant effect of warfarin.
B. "Avoid grapefruit juice.": While grapefruit juice can interact with many medications, it does not significantly affect warfarin.
C. "Limit your intake of vitamin K-rich foods.": Vitamin K can counteract the effects of warfarin, so patients should maintain a consistent intake to avoid fluctuations in their INR.
D. "Take the medication with a high-fat meal.": Warfarin absorption is not significantly affected by fat intake.

References:

National Council of State Boards of Nursing (NCSBN). (2020). NCLEX-PN Examination Candidate Bulletin.
American Heart Association. (2023). Warfarin Therapy Guidelines.
Lilley, L. L., Collins, S. R., & Snyder, J. S. (2019). Pharmacology and the Nursing Process. Elsevier.
39
13). A 50-year-old male is admitted with symptoms of acute pancreatitis. Which laboratory value is most indicative of this condition?
Elevated serum bilirubin
Elevated serum amylase
Decreased serum albumin
Decreased serum calcium
40
Correct Answer: B. Elevated serum amylase

Rationale:

A. Elevated serum bilirubin: This may indicate liver or biliary disease but is not specific to pancreatitis.
B. Elevated serum amylase: Elevated serum amylase and lipase are the most specific indicators of acute pancreatitis.
C. Decreased serum albumin: This may occur in chronic liver disease or malnutrition but is not specific to pancreatitis.
D. Decreased serum calcium: Hypocalcemia can occur in severe pancreatitis but is not the primary diagnostic marker.

References:

National Council of State Boards of Nursing (NCSBN). (2020). NCLEX-PN Examination Candidate Bulletin.
American College of Gastroenterology. (2023). Guidelines for the Management of Acute Pancreatitis.
McCance, K. L., & Huether, S. E. (2018). Pathophysiology: The Biologic Basis for Disease in Adults and Children. Elsevier.
41
Incorrect

Correct Answer: B. Elevated serum amylase

Rationale:

A. Elevated serum bilirubin: This may indicate liver or biliary disease but is not specific to pancreatitis.
B. Elevated serum amylase: Elevated serum amylase and lipase are the most specific indicators of acute pancreatitis.
C. Decreased serum albumin: This may occur in chronic liver disease or malnutrition but is not specific to pancreatitis.
D. Decreased serum calcium: Hypocalcemia can occur in severe pancreatitis but is not the primary diagnostic marker.

References:

National Council of State Boards of Nursing (NCSBN). (2020). NCLEX-PN Examination Candidate Bulletin.
American College of Gastroenterology. (2023). Guidelines for the Management of Acute Pancreatitis.
McCance, K. L., & Huether, S. E. (2018). Pathophysiology: The Biologic Basis for Disease in Adults and Children. Elsevier.
42
14). A 35-year-old female patient is undergoing treatment for major depressive disorder with sertraline (Zoloft). Which side effect should the nurse prioritize monitoring for?
Weight gain
Sexual dysfunction
Insomnia
Suicidal ideation
43
Correct Answer: D. Suicidal ideation

Rationale:

A. Weight gain: While weight gain can be a side effect of SSRIs, it is not the highest priority.
B. Insomnia: Insomnia can occur with SSRIs but is not the most critical side effect to monitor.
C. Sexual dysfunction: This is a common side effect of SSRIs but not the most urgent.
D. Suicidal ideation: The risk of suicidal thoughts and behaviors can increase, especially when starting the medication or changing the dose. This is the most critical side effect to monitor.

References:

National Council of State Boards of Nursing (NCSBN). (2020). NCLEX-PN Examination Candidate Bulletin.
American Psychiatric Association. (2023). Practice Guidelines for the Treatment of Patients with Major Depressive Disorder.
Lilley, L. L., Collins, S. R., & Snyder, J. S. (2019). Pharmacology and the Nursing Process. Elsevier.
44
Incorrect

correct Correct Answer: D. Suicidal ideation

Rationale:

A. Weight gain: While weight gain can be a side effect of SSRIs, it is not the highest priority.
B. Insomnia: Insomnia can occur with SSRIs but is not the most critical side effect to monitor.
C. Sexual dysfunction: This is a common side effect of SSRIs but not the most urgent.
D. Suicidal ideation: The risk of suicidal thoughts and behaviors can increase, especially when starting the medication or changing the dose. This is the most critical side effect to monitor.

References:

National Council of State Boards of Nursing (NCSBN). (2020). NCLEX-PN Examination Candidate Bulletin.
American Psychiatric Association. (2023). Practice Guidelines for the Treatment of Patients with Major Depressive Disorder.
Lilley, L. L., Collins, S. R., & Snyder, J. S. (2019). Pharmacology and the Nursing Process. Elsevier.
45
15). A practical/vocational nurse (LPN/VN) is assigned to a long-term care facility. Which actions should the nurse prioritize to ensure effective client care coordination?
Develop a care plan independently for each client.
Assign tasks to nursing assistants based on their preferences.
Schedule a multidisciplinary team meeting to discuss client care.
Inform clients’ families about their care plans without consulting other team members.
46
Correct Answer: C. Schedule a multidisciplinary team meeting to discuss client care.

Rationale: Effective client care coordination involves collaboration with the interdisciplinary team to ensure comprehensive and consistent care. Scheduling a multidisciplinary team meeting allows for the input and expertise of various healthcare professionals, which enhances the quality of care provided to clients. This approach is essential for addressing all aspects of a client’s needs and ensures that care plans are well-coordinated and effective.
47
Incorrect

Correct Answer: C. Schedule a multidisciplinary team meeting to discuss client care.

Rationale: Effective client care coordination involves collaboration with the interdisciplinary team to ensure comprehensive and consistent care. Scheduling a multidisciplinary team meeting allows for the input and expertise of various healthcare professionals, which enhances the quality of care provided to clients. This approach is essential for addressing all aspects of a client’s needs and ensures that care plans are well-coordinated and effective.
48
16). A practical/vocational nurse is assigned to care for four clients. Which of the following tasks should the nurse delegate to a certified nursing assistant (CNA)?
Administering oral medications to a client with diabetes.
Educating a client about postoperative wound care.
Assisting a client with ambulation who recently had a hip replacement.
Developing a care plan for a client with chronic obstructive pulmonary disease (COPD).
49
Correct

Rationale: According to the principles of coordinated care, tasks delegated to unlicensed assistive personnel (UAP), such as CNAs, should be within their scope of practice and training. Assisting with ambulation is a basic care task appropriate for a CNA. Administering medications, providing client education, and developing care plans require the specialized knowledge and skills of a licensed nurse and should not be delegated to a CNA.

Reference:

NCLEX-PN Test Plan - Coordinated Care: The practical/vocational nurse collaborates with health care team members to facilitate effective client care, including appropriate delegation of tasks (2014 NCLEX-PN Test Plan, page 6).
50
Incorrect

Rationale: According to the principles of coordinated care, tasks delegated to unlicensed assistive personnel (UAP), such as CNAs, should be within their scope of practice and training. Assisting with ambulation is a basic care task appropriate for a CNA. Administering medications, providing client education, and developing care plans require the specialized knowledge and skills of a licensed nurse and should not be delegated to a CNA.

Reference:

NCLEX-PN Test Plan - Coordinated Care: The practical/vocational nurse collaborates with health care team members to facilitate effective client care, including appropriate delegation of tasks (2014 NCLEX-PN Test Plan, page 6).
51
17). A licensed practical/vocational nurse (LPN/VN) works in a long-term care facility. Which action demonstrates effective use of the interdisciplinary team?
Adjusting a client’s medication dosage based on observed side effects.
Conducting a family meeting to discuss the client's care plan and progress.
Referring a client to a dietitian for nutritional counseling.
Performing a physical assessment on a newly admitted client.
52
Answer: C. Referring a client to a dietitian for nutritional counseling.

Rationale: Effective coordinated care involves utilizing the skills and expertise of the interdisciplinary team to meet the client’s needs. Referring a client to a dietitian for nutritional counseling ensures the client receives specialized advice on diet and nutrition, which is within the scope of practice for a dietitian and demonstrates effective collaboration.

Reference:

NCLEX-PN Test Plan - Coordinated Care: The practical/vocational nurse collaborates with health care team members to facilitate effective client care, including making appropriate referrals (2014 NCLEX-PN Test Plan, page 6).
53
Incorrect

Answer: C. Referring a client to a dietitian for nutritional counseling.

Rationale: Effective coordinated care involves utilizing the skills and expertise of the interdisciplinary team to meet the client’s needs. Referring a client to a dietitian for nutritional counseling ensures the client receives specialized advice on diet and nutrition, which is within the scope of practice for a dietitian and demonstrates effective collaboration.

Reference:

NCLEX-PN Test Plan - Coordinated Care: The practical/vocational nurse collaborates with health care team members to facilitate effective client care, including making appropriate referrals (2014 NCLEX-PN Test Plan, page 6).
54
18). A practical/vocational nurse cares for a client requiring complex wound care. Which of the following actions best demonstrates adherence to ethical principles?
Performing the wound care without consulting the client’s preference.
Documenting the wound care procedure accurately in the client’s medical record.
Delegating the wound care to a newly hired CNA who is eager to learn.
Requesting additional training before performing a new wound care technique.
55
Answer: D. Requesting additional training before performing a new wound care technique.

Rationale: Adherence to ethical principles in nursing includes ensuring competence in performing procedures. By requesting additional training, the nurse demonstrates a commitment to providing safe and competent care, thereby upholding ethical standards.

Reference: NCLEX-PN Test Plan - Coordinated Care: Ethical practice and ensuring competence in nursing tasks (2014 NCLEX-PN Test Plan, page 6).
56
Incorrect

Answer: D. Requesting additional training before performing a new wound care technique.

Rationale: Adherence to ethical principles in nursing includes ensuring competence in performing procedures. By requesting additional training, the nurse demonstrates a commitment to providing safe and competent care, thereby upholding ethical standards.

Reference: NCLEX-PN Test Plan - Coordinated Care: Ethical practice and ensuring competence in nursing tasks (2014 NCLEX-PN Test Plan, page 6).
57
19). A practical/vocational nurse is preparing for shift handoff. Which information is most important to include in the report to ensure continuity of care?
The client’s favorite activities and hobbies.
The names of the client’s family members who visited.
Any changes in the client’s condition or treatment plan.
The client’s dietary preferences and dislikes.
58
Answer: C. Any changes in the client’s condition or treatment plan.

Rationale: Continuity of care requires effective communication during shift handoffs, especially regarding any changes in the client’s condition or treatment plan. This information is critical for the incoming nurse to provide safe and effective care.

Reference: NCLEX-PN Test Plan - Coordinated Care: Continuity of care and effective communication during handoffs (2014 NCLEX-PN Test Plan, page 7).
59
Incorrect

Answer: C. Any changes in the client’s condition or treatment plan.

Rationale: Continuity of care requires effective communication during shift handoffs, especially regarding any changes in the client’s condition or treatment plan. This information is critical for the incoming nurse to provide safe and effective care.

Reference: NCLEX-PN Test Plan - Coordinated Care: Continuity of care and effective communication during handoffs (2014 NCLEX-PN Test Plan, page 7).
60
20). A practical/vocational nurse is assigned to care for a client who does not speak English. Which action best ensures effective communication and care coordination?
Asking the client’s family to interpret.
Using a certified medical interpreter.
Speaking louder and more slowly.
Using gestures and non-verbal cues.
61
Answer: B. Using a certified medical interpreter.

Rationale: Using a certified medical interpreter ensures accurate and effective communication, which is essential for providing safe and coordinated care. This approach respects the client’s right to understand their care and participate in decision-making.

Reference: NCLEX-PN Test Plan - Coordinated Care: Effective communication and respecting client rights (2014 NCLEX-PN Test Plan, page 6).
62
Incorrect

Answer: B. Using a certified medical interpreter.

Rationale: Using a certified medical interpreter ensures accurate and effective communication, which is essential for providing safe and coordinated care. This approach respects the client’s right to understand their care and participate in decision-making.

Reference: NCLEX-PN Test Plan - Coordinated Care: Effective communication and respecting client rights (2014 NCLEX-PN Test Plan, page 6).
63
21). A practical/vocational nurse (LPN/VN) is working with a client who has a new diagnosis of diabetes mellitus. The client needs to learn how to administer insulin injections. Which action should the nurse take to ensure the client receives the appropriate education?
Provide the client with a pamphlet on diabetes management and insulin administration.
Delegate the education session to a certified nursing assistant (CNA).
Arrange for a diabetes educator to teach the client about insulin administration.
Ask the client to watch a video on insulin administration and answer any questions afterward.
64
Answer: C. Arrange for a diabetes educator to teach the client about insulin administration.

Rationale: A diabetes educator has specialized knowledge and skills in diabetes management and can provide comprehensive education on insulin administration, ensuring the client receives accurate and detailed information.

Reference: NCLEX-PN Test Plan - Coordinated Care: Collaboration with interdisciplinary team members to facilitate effective client education (2014 NCLEX-PN Test Plan, page 6).
65
Incorrect

Answer: C. Arrange for a diabetes educator to teach the client about insulin administration.

Rationale: A diabetes educator has specialized knowledge and skills in diabetes management and can provide comprehensive education on insulin administration, ensuring the client receives accurate and detailed information.

Reference: NCLEX-PN Test Plan - Coordinated Care: Collaboration with interdisciplinary team members to facilitate effective client education (2014 NCLEX-PN Test Plan, page 6).
66
22). A practical/vocational nurse is part of a healthcare team that includes RNs, physicians, and physical therapists. To which team member should the nurse report a client’s newly developed pressure ulcer?
The physical therapist.
The physician.
The registered nurse (RN).
The unit secretary.
67
Answer: B. The registered nurse (RN).

Rationale: The registered nurse (RN) is responsible for overseeing the client’s overall care and coordinating with other healthcare team members. Reporting the pressure ulcer to the RN ensures timely and appropriate interventions are implemented.

Reference: NCLEX-PN Test Plan - Coordinated Care: Collaboration and communication with healthcare team members (2014 NCLEX-PN Test Plan, page 6).
68
Incorrect

Answer: B. The registered nurse (RN).

Rationale: The registered nurse (RN) is responsible for overseeing the client’s overall care and coordinating with other healthcare team members. Reporting the pressure ulcer to the RN ensures timely and appropriate interventions are implemented.

Reference: NCLEX-PN Test Plan - Coordinated Care: Collaboration and communication with healthcare team members (2014 NCLEX-PN Test Plan, page 6).
69
23). A practical/vocational nurse is preparing to discharge a client with heart failure. Which action is essential to ensure the client’s continuity of care after discharge?
Scheduling a follow-up appointment with the primary care provider.
Providing the client with a list of their medications.
Teaching the client how to measure their blood pressure at home.
Giving the client contact information for a local support group.
70
Answer: A. Scheduling a follow-up appointment with the primary care provider.

Rationale: Scheduling a follow-up appointment ensures that the client will receive ongoing medical oversight and management of their condition, which is critical for continuity of care.

Reference: NCLEX-PN Test Plan - Coordinated Care: Ensuring continuity of care through appropriate follow-up and referrals (2014 NCLEX-PN Test Plan, page 6).
71
Incorrect

Answer: A. Scheduling a follow-up appointment with the primary care provider.

Rationale: Scheduling a follow-up appointment ensures that the client will receive ongoing medical oversight and management of their condition, which is critical for continuity of care.

Reference: NCLEX-PN Test Plan - Coordinated Care: Ensuring continuity of care through appropriate follow-up and referrals (2014 NCLEX-PN Test Plan, page 6).
72
24). A practical/vocational nurse observes a colleague discussing a client’s medical condition with another staff member in a public area. What should the nurse do to address this breach of confidentiality?
Inform the client about the breach of confidentiality.
Report the incident to the nurse manager immediately.
Confront the colleague in the public area.
Ignore the situation to avoid conflict.
73
Answer: B. Report the incident to the nurse manager immediately.

Rationale: Reporting the incident to the nurse manager ensures that the breach of confidentiality is addressed appropriately and promptly, maintaining the integrity and privacy of client information.

Reference: NCLEX-PN Test Plan - Coordinated Care: Confidentiality and information security (2014 NCLEX-PN Test Plan, page 6).
74
Incorrect

Answer: B. Report the incident to the nurse manager immediately.

Rationale: Reporting the incident to the nurse manager ensures that the breach of confidentiality is addressed appropriately and promptly, maintaining the integrity and privacy of client information.

Reference: NCLEX-PN Test Plan - Coordinated Care: Confidentiality and information security (2014 NCLEX-PN Test Plan, page 6).
75
25). A practical/vocational nurse coordinates the care of a client with multiple chronic conditions. Which resource is most appropriate for managing the client’s home health care needs?
The client’s family members.
A home health care agency.
A local community center.
The client’s primary care provider.
76
Answer: B. A home health care agency.

Rationale: A home health care agency can provide comprehensive services, including skilled nursing care, physical therapy, and assistance with activities of daily living, ensuring the client’s complex needs are met in their home environment.

Reference: NCLEX-PN Test Plan - Coordinated Care: Referral process and resource management (2014 NCLEX-PN Test Plan, page 6).
77
Incorrect

Answer: B. A home health care agency.

Rationale: A home health care agency can provide comprehensive services, including skilled nursing care, physical therapy, and assistance with activities of daily living, ensuring the client’s complex needs are met in their home environment.

Reference: NCLEX-PN Test Plan - Coordinated Care: Referral process and resource management (2014 NCLEX-PN Test Plan, page 6).
78
26). A nurse is educating new parents about the importance of immunizations for their infants. Which of the following statements should the nurse include in the teaching?
"It is safe to delay vaccinations if your child has a mild illness such as a cold."
"Vaccinations should start when your child is 1 year old to ensure proper development."
"Vaccinations are important to prevent the spread of infectious diseases in the community."
"Once your child receives all the required vaccines, no booster doses are necessary."
79
Correct Answer: C. "Vaccinations are important to prevent the spread of infectious diseases in the community."

Rationale: Vaccinations are a critical component of public health as they help prevent the spread of infectious diseases. They protect not only the vaccinated individual but also contribute to community immunity, thereby reducing the incidence of diseases within the population.

Reference: This question pertains to the Health Promotion and Maintenance category of the NCLEX-PN Test Plan, which involves providing nursing care that incorporates knowledge of expected stages of growth and development, and prevention and/or early detection of health problems.
80
Incorrect

Correct Answer: C. "Vaccinations are important to prevent the spread of infectious diseases in the community."

Rationale: Vaccinations are a critical component of public health as they help prevent the spread of infectious diseases. They protect not only the vaccinated individual but also contribute to community immunity, thereby reducing the incidence of diseases within the population.

Reference: This question pertains to the Health Promotion and Maintenance category of the NCLEX-PN Test Plan, which involves providing nursing care that incorporates knowledge of expected stages of growth and development, and prevention and/or early detection of health problems.
81
27). A nurse is conducting a prenatal class for expectant mothers. Which of the following topics should the nurse prioritize to promote fetal health?
The importance of prenatal vitamins, including folic acid, to prevent neural tube defects.
The benefits of an exercise regimen focusing on high-intensity workouts during pregnancy.
The need to increase caloric intake by 800 calories per day throughout the entire pregnancy.
The effectiveness of herbal supplements in managing morning sickness.
82
Correct Answer: A. The importance of prenatal vitamins, including folic acid, to prevent neural tube defects.

Rationale: Prenatal vitamins, especially folic acid, are crucial in preventing neural tube defects such as spina bifida. It is essential for pregnant women to understand the importance of these vitamins for the health and development of their fetus.

Reference: This question relates to the Health Promotion and Maintenance category of the NCLEX-PN Test Plan, focusing on antepartum care and the promotion of health and disease prevention during pregnancy.
83
Incorrect

Correct Answer: A. The importance of prenatal vitamins, including folic acid, to prevent neural tube defects.

Rationale: Prenatal vitamins, especially folic acid, are crucial in preventing neural tube defects such as spina bifida. It is essential for pregnant women to understand the importance of these vitamins for the health and development of their fetus.

Reference: This question relates to the Health Promotion and Maintenance category of the NCLEX-PN Test Plan, focusing on antepartum care and the promotion of health and disease prevention during pregnancy.
84
28). A nurse educates a 50-year-old client about colorectal cancer screening. Which of the following statements should the nurse include?
"You should have a fecal occult blood test every five years starting at age 50."
"A colonoscopy is recommended every 10 years starting at age 50."
"If you have a family history of colorectal cancer, you can start screening at age 60."
"Once you start screening, you only need to continue if you experience symptoms."
85
Correct Answer: B. "A colonoscopy is recommended every 10 years starting at age 50."

Rationale: Colorectal cancer screening is an important preventive measure. The recommendation is to have a colonoscopy every 10 years starting at age 50 to detect any early signs of cancer.

Reference: This question pertains to the Health Promotion and Maintenance category of the NCLEX-PN Test Plan, involving knowledge of health promotion and disease prevention strategies for adults.
86
Incorrect

Correct Answer: B. "A colonoscopy is recommended every 10 years starting at age 50."

Rationale: Colorectal cancer screening is an important preventive measure. The recommendation is to have a colonoscopy every 10 years starting at age 50 to detect any early signs of cancer.

Reference: This question pertains to the Health Promotion and Maintenance category of the NCLEX-PN Test Plan, involving knowledge of health promotion and disease prevention strategies for adults.
87
29). During a routine health visit, a nurse educates a client about lifestyle choices that reduce the risk of cardiovascular disease. Which of the following recommendations should the nurse make?
"Limit your intake of fruits and vegetables to reduce sugar intake."
"Engage in at least 150 minutes of moderate-intensity exercise per week."
"Increase your daily intake of saturated fats to improve heart health."
"Avoid all forms of physical activity to reduce the risk of injury."
88
Correct Answer: B. "Engage in at least 150 minutes of moderate-intensity exercise per week."

Rationale: Regular physical activity, such as 150 minutes of moderate-intensity exercise per week, is beneficial for cardiovascular health. It helps reduce the risk of heart disease and other related conditions.

Reference: This question relates to the Health Promotion and Maintenance category of the NCLEX-PN Test Plan, focusing on lifestyle choices and behaviors that promote health and prevent disease.
89
Incorrect

Correct Answer: B. "Engage in at least 150 minutes of moderate-intensity exercise per week."

Rationale: Regular physical activity, such as 150 minutes of moderate-intensity exercise per week, is beneficial for cardiovascular health. It helps reduce the risk of heart disease and other related conditions.

Reference: This question relates to the Health Promotion and Maintenance category of the NCLEX-PN Test Plan, focusing on lifestyle choices and behaviors that promote health and prevent disease.
90
30). A nurse is conducting a prenatal class for a group of expectant mothers. Which of the following statements should the nurse include when discussing the importance of folic acid in pregnancy?
"Folic acid helps prevent neural tube defects in the developing fetus."
"Folic acid is important for increasing the mother's iron levels."
"Folic acid aids in the digestion and absorption of nutrients."
"Folic acid reduces the risk of preterm labor and delivery."
91
Answer: A. "Folic acid helps prevent neural tube defects in the developing fetus."

Rationale: Folic acid is crucial during pregnancy as it helps in the prevention of neural tube defects, which are serious birth defects of the brain and spine. It is recommended that women who are planning to become pregnant or who are in the early stages of pregnancy take folic acid supplements to reduce the risk of these defects.

Reference: 2014 NCLEX-PN® Test Plan, Health Promotion and Maintenance: "The practical/vocational nurse provides nursing care for clients that incorporate the knowledge of expected stages of growth and development, and prevention and/or early detection of health problems".
92
Incorrect

Answer: A. "Folic acid helps prevent neural tube defects in the developing fetus."

Rationale: Folic acid is crucial during pregnancy as it helps in the prevention of neural tube defects, which are serious birth defects of the brain and spine. It is recommended that women who are planning to become pregnant or who are in the early stages of pregnancy take folic acid supplements to reduce the risk of these defects.

Reference: 2014 NCLEX-PN® Test Plan, Health Promotion and Maintenance: "The practical/vocational nurse provides nursing care for clients that incorporate the knowledge of expected stages of growth and development, and prevention and/or early detection of health problems".
93
31). A nurse is preparing to administer digoxin to a client with heart failure. The client’s serum digoxin level is 2.6 ng/mL. Which of the following actions should the nurse take?
Administer the medication as scheduled.
Hold the medication and notify the healthcare provider.
Administer half of the prescribed dose.
Check the client’s apical pulse and administer the medication if the pulse is above 60 beats per minute.
94
Answer:
B. Hold the medication and notify the healthcare provider.

Rationale:
The therapeutic range for serum digoxin levels is typically between 0.8 and 2.0 ng/mL. A level of 2.6 ng/mL is above the therapeutic range and indicates potential digoxin toxicity. The nurse should hold the medication and notify the healthcare provider to prevent adverse effects associated with digoxin toxicity.

Reference:
This question pertains to the "Pharmacological Therapies" category under "Physiological Integrity," specifically focusing on the "Expected Actions/Outcomes" and "Adverse Effects/Contraindications/Side Effects/Interactions" subtopics. Refer to the 2014 NCLEX-PN Test Plan, page 8 for content related to pharmacological therapies and monitoring of medication effects.
95
Incorrect

Answer:
B. Hold the medication and notify the healthcare provider.

Rationale:
The therapeutic range for serum digoxin levels is typically between 0.8 and 2.0 ng/mL. A level of 2.6 ng/mL is above the therapeutic range and indicates potential digoxin toxicity. The nurse should hold the medication and notify the healthcare provider to prevent adverse effects associated with digoxin toxicity.

Reference:
This question pertains to the "Pharmacological Therapies" category under "Physiological Integrity," specifically focusing on the "Expected Actions/Outcomes" and "Adverse Effects/Contraindications/Side Effects/Interactions" subtopics. Refer to the 2014 NCLEX-PN Test Plan, page 8 for content related to pharmacological therapies and monitoring of medication effects.
96
32). A client who has been prescribed prednisone for chronic asthma asks about the medication's long-term effects. Which of the following should the nurse include in the teaching?
"You may experience weight loss."
"Monitor your blood glucose levels regularly."
"You can stop taking the medication abruptly if you feel better."
"Avoid all types of physical exercise."
97
Answer:
B. "Monitor your blood glucose levels regularly."

Rationale:
Long-term use of prednisone, a corticosteroid, can lead to hyperglycemia. Clients should be advised to monitor their blood glucose levels regularly. Other long-term effects include weight gain, osteoporosis, and increased risk of infection. Prednisone should not be stopped abruptly due to the risk of adrenal insufficiency.

Reference:
This question pertains to the "Pharmacological Therapies" category, focusing on "Client Education" and "Adverse Effects/Contraindications/Side Effects/Interactions." Refer to the 2014 NCLEX-PN Test Plan, page 8 for client teaching regarding corticosteroid therapy.
98
Incorrect

Answer:
B. "Monitor your blood glucose levels regularly."

Rationale:
Long-term use of prednisone, a corticosteroid, can lead to hyperglycemia. Clients should be advised to monitor their blood glucose levels regularly. Other long-term effects include weight gain, osteoporosis, and increased risk of infection. Prednisone should not be stopped abruptly due to the risk of adrenal insufficiency.

Reference:
This question pertains to the "Pharmacological Therapies" category, focusing on "Client Education" and "Adverse Effects/Contraindications/Side Effects/Interactions." Refer to the 2014 NCLEX-PN Test Plan, page 8 for client teaching regarding corticosteroid therapy.
99
33). A nurse is administering furosemide to a client with heart failure. Which of the following laboratory values should the nurse monitor due to the risk associated with this medication?
Hemoglobin and hematocrit
Blood urea nitrogen (BUN) and creatinine
Serum potassium and sodium
Serum glucose and calcium
100
Answer:
C. Serum potassium and sodium

Rationale:
Furosemide is a loop diuretic that can cause significant electrolyte imbalances, particularly hypokalemia (low potassium) and hyponatremia (low sodium). Monitoring these levels is essential to prevent complications such as arrhythmias and muscle weakness.

Reference:
This question is associated with the "Pharmacological Therapies" category, specifically "Expected Actions/Outcomes" and "Adverse Effects/Contraindications/Side Effects/Interactions." Refer to the 2014 NCLEX-PN Test Plan, page 8 for monitoring the effects of diuretic therapy.
101
Incorrect

Answer:
C. Serum potassium and sodium

Rationale:
Furosemide is a loop diuretic that can cause significant electrolyte imbalances, particularly hypokalemia (low potassium) and hyponatremia (low sodium). Monitoring these levels is essential to prevent complications such as arrhythmias and muscle weakness.

Reference:
This question is associated with the "Pharmacological Therapies" category, specifically "Expected Actions/Outcomes" and "Adverse Effects/Contraindications/Side Effects/Interactions." Refer to the 2014 NCLEX-PN Test Plan, page 8 for monitoring the effects of diuretic therapy.
102
34). A nurse is reviewing the laboratory results of a client taking lithium carbonate for bipolar disorder. The serum lithium level is 1.6 mEq/L. Which of the following actions should the nurse take?
Administer the next dose as scheduled.
Encourage the client to drink 2-3 liters of water daily.
Withhold the medication and notify the healthcare provider.
Assess the client for signs of lithium toxicity.
103
Answer:
C. Withhold the medication and notify the healthcare provider.

Rationale:
A serum lithium level of 1.6 mEq/L is above the therapeutic range (0.6 to 1.2 mEq/L) and may indicate lithium toxicity. The nurse should withhold the medication and notify the healthcare provider immediately. Encouraging fluid intake and assessing for signs of toxicity are important but withholding the medication takes priority to prevent further toxicity.

Reference:
This question falls under the "Pharmacological Therapies" category, focusing on "Adverse Effects/Contraindications/Side Effects/Interactions" and "Expected Actions/Outcomes." Refer to the 2014 NCLEX-PN Test Plan, page 8 for managing high-risk medications and client safety.
104
Incorrect

Answer:
C. Withhold the medication and notify the healthcare provider.

Rationale:
A serum lithium level of 1.6 mEq/L is above the therapeutic range (0.6 to 1.2 mEq/L) and may indicate lithium toxicity. The nurse should withhold the medication and notify the healthcare provider immediately. Encouraging fluid intake and assessing for signs of toxicity are important but withholding the medication takes priority to prevent further toxicity.

Reference:
This question falls under the "Pharmacological Therapies" category, focusing on "Adverse Effects/Contraindications/Side Effects/Interactions" and "Expected Actions/Outcomes." Refer to the 2014 NCLEX-PN Test Plan, page 8 for managing high-risk medications and client safety.
105
35). A nurse is preparing to administer an IM injection of penicillin to a client. The client states that they have never received this medication before. What is the nurse’s priority action?
Administer the medication and observe the client for 30 minutes.
Ask the client about any known allergies.
Prepare to administer an antihistamine.
Notify the healthcare provider.
106
Answer:
B. Ask the client about any known allergies.

Rationale:
Before administering penicillin, it is crucial to assess the client for any known allergies to avoid potential allergic reactions. Observing the client after administration is important, but identifying allergies prior to administration is the priority. Preparing to administer an antihistamine and notifying the healthcare provider are secondary actions that depend on the client’s allergy history and response to the medication.

Reference:
This question is relevant to the "Pharmacological Therapies" category, particularly "Adverse Effects/Contraindications/Side Effects/Interactions." Refer to the 2014 NCLEX-PN Test Plan, page 8 for content on client assessment prior to medication administration.
107
Incorrect

Answer:
B. Ask the client about any known allergies.

Rationale:
Before administering penicillin, it is crucial to assess the client for any known allergies to avoid potential allergic reactions. Observing the client after administration is important, but identifying allergies prior to administration is the priority. Preparing to administer an antihistamine and notifying the healthcare provider are secondary actions that depend on the client’s allergy history and response to the medication.

Reference:
This question is relevant to the "Pharmacological Therapies" category, particularly "Adverse Effects/Contraindications/Side Effects/Interactions." Refer to the 2014 NCLEX-PN Test Plan, page 8 for content on client assessment prior to medication administration.
108
36). A nurse is teaching a client with type 2 diabetes mellitus about the new metformin prescription. Which of the following statements indicates a need for further teaching?
"I should take my medication with meals to decrease stomach upset."
"I will avoid alcohol while taking this medication."
"I need to check my blood sugar levels regularly."
"I can skip doses if my blood sugar levels are within the normal range."
109
Answer:
D. "I can skip doses if my blood sugar levels are within the normal range."

Rationale:
Clients should take metformin consistently as prescribed to maintain stable blood glucose levels. Skipping doses can lead to poor blood glucose control. Taking metformin with meals can help reduce gastrointestinal side effects, avoiding alcohol is important due to the risk of lactic acidosis, and regular blood sugar monitoring is essential for managing diabetes effectively.

Reference:
This question falls under the "Pharmacological Therapies" category, specifically focusing on "Medication Administration" and "Client Education." Refer to the 2014 NCLEX-PN Test Plan, page 8 for content related to client teaching and medication compliance.
110
Incorrect

Answer:
D. "I can skip doses if my blood sugar levels are within the normal range."

Rationale:
Clients should take metformin consistently as prescribed to maintain stable blood glucose levels. Skipping doses can lead to poor blood glucose control. Taking metformin with meals can help reduce gastrointestinal side effects, avoiding alcohol is important due to the risk of lactic acidosis, and regular blood sugar monitoring is essential for managing diabetes effectively.

Reference:
This question falls under the "Pharmacological Therapies" category, specifically focusing on "Medication Administration" and "Client Education." Refer to the 2014 NCLEX-PN Test Plan, page 8 for content related to client teaching and medication compliance.
111
37). A client receiving intravenous morphine sulfate for postoperative pain reports severe itching. Which of the following should be the nurse's priority action?
Decrease the rate of the infusion.
Administer a dose of diphenhydramine as prescribed.
Discontinue the morphine sulfate infusion immediately.
Document the itching as a side effect of morphine.
112
Answer:
B. Administer a dose of diphenhydramine as prescribed.

Rationale:
Itching is a common side effect of morphine sulfate, and administering an antihistamine like diphenhydramine can help alleviate this symptom. Decreasing the rate of infusion might not address the itching effectively. Discontinuing the infusion immediately should be done only if the client exhibits signs of a severe allergic reaction or anaphylaxis. Documenting is important but addressing the client's immediate discomfort takes priority.

Reference:
This question pertains to the "Pharmacological Therapies" category under "Adverse Effects/Contraindications/Side Effects/Interactions." Refer to the 2014 NCLEX-PN Test Plan, page 8 for managing medication side effects and appropriate nursing interventions.
113
Incorrect

Answer:
B. Administer a dose of diphenhydramine as prescribed.

Rationale:
Itching is a common side effect of morphine sulfate, and administering an antihistamine like diphenhydramine can help alleviate this symptom. Decreasing the rate of infusion might not address the itching effectively. Discontinuing the infusion immediately should be done only if the client exhibits signs of a severe allergic reaction or anaphylaxis. Documenting is important but addressing the client's immediate discomfort takes priority.

Reference:
This question pertains to the "Pharmacological Therapies" category under "Adverse Effects/Contraindications/Side Effects/Interactions." Refer to the 2014 NCLEX-PN Test Plan, page 8 for managing medication side effects and appropriate nursing interventions.
114
38). A nurse is providing education to a client who has been prescribed warfarin for atrial fibrillation. Which of the following instructions should the nurse include?
Increase the intake of green leafy vegetables.
Use a soft-bristle toothbrush to prevent gum bleeding.
Take aspirin for headaches.
Expect increased bruising as a normal side effect.
115
Answer:
B. Use a soft-bristle toothbrush to prevent gum bleeding.

Rationale:
Warfarin is an anticoagulant that increases the risk of bleeding. Using a soft-bristle toothbrush helps prevent gum bleeding, which is a potential side effect of anticoagulant therapy. Increasing the intake of green leafy vegetables (which are high in vitamin K) can counteract the effect of warfarin. Taking aspirin can further increase the risk of bleeding. While bruising can occur, it should not be considered normal and should be reported to the healthcare provider.

Reference:
This question is related to the "Pharmacological Therapies" category, focusing on "Medication Administration" and "Reduction of Risk Potential." Refer to the 2014 NCLEX-PN Test Plan, page 8 for content on medication side effects and client education.
116
Incorrect

Answer:
B. Use a soft-bristle toothbrush to prevent gum bleeding.

Rationale:
Warfarin is an anticoagulant that increases the risk of bleeding. Using a soft-bristle toothbrush helps prevent gum bleeding, which is a potential side effect of anticoagulant therapy. Increasing the intake of green leafy vegetables (which are high in vitamin K) can counteract the effect of warfarin. Taking aspirin can further increase the risk of bleeding. While bruising can occur, it should not be considered normal and should be reported to the healthcare provider.

Reference:
This question is related to the "Pharmacological Therapies" category, focusing on "Medication Administration" and "Reduction of Risk Potential." Refer to the 2014 NCLEX-PN Test Plan, page 8 for content on medication side effects and client education.
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39). A 40-year-old patient is admitted to the psychiatric unit with a diagnosis of major depressive disorder. The patient reports feelings of worthlessness and hopelessness. Which of the following interventions should the nurse implement first?
Encourage the patient to participate in group therapy sessions.
Conduct a thorough suicide risk assessment.
Administer the prescribed antidepressant medication.
Assist the patient in developing a daily activity schedule.
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Correct Answer: B) Conduct a thorough suicide risk assessment.

Rationale: Conducting a thorough suicide risk assessment is the priority intervention for a patient with major depressive disorder reporting feelings of worthlessness and hopelessness. Ensuring the patient's safety is paramount before proceeding with other therapeutic interventions.

Reference: Lewis, S. M., Dirksen, S. R., Heitkemper, M. M., Bucher, L., & Harding, M. M. (2014). Medical-Surgical Nursing: Assessment and Management of Clinical Problems (9th ed.). Elsevier. (Chapter on Psychiatric Nursing Care)
119
Incorrect

Correct Answer: B) Conduct a thorough suicide risk assessment.

Rationale: Conducting a thorough suicide risk assessment is the priority intervention for a patient with major depressive disorder reporting feelings of worthlessness and hopelessness. Ensuring the patient's safety is paramount before proceeding with other therapeutic interventions.

Reference: Lewis, S. M., Dirksen, S. R., Heitkemper, M. M., Bucher, L., & Harding, M. M. (2014). Medical-Surgical Nursing: Assessment and Management of Clinical Problems (9th ed.). Elsevier. (Chapter on Psychiatric Nursing Care)
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40). A nurse is caring for a client with schizophrenia who is experiencing auditory hallucinations. Which of the following responses by the nurse is most appropriate?
"I don't hear any voices. Are you sure you're hearing them?"
"It must be frightening to hear voices. Let's talk about what they're saying."
"Those voices aren't real, so you can just ignore them."
"You need to stop listening to those voices and focus on reality."
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Correct Answer: B) "It must be frightening to hear voices. Let's talk about what they're saying."

Rationale: Acknowledge the client's experience and offer to discuss the content of the hallucinations, providing emotional support and promoting a trusting nurse-client relationship. This approach helps the client feel understood and supported.

Reference: Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. M. (2016). Fundamentals of Nursing (9th ed.). Elsevier. (Chapter on Communication and Mental Health Nursing)
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Incorrect

Correct Answer: B) "It must be frightening to hear voices. Let's talk about what they're saying."

Rationale: Acknowledge the client's experience and offer to discuss the content of the hallucinations, providing emotional support and promoting a trusting nurse-client relationship. This approach helps the client feel understood and supported.

Reference: Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. M. (2016). Fundamentals of Nursing (9th ed.). Elsevier. (Chapter on Communication and Mental Health Nursing)
123
41). A patient with generalized anxiety disorder is being treated with cognitive-behavioral therapy (CBT). Which of the following statements by the patient indicates an understanding of the therapy?
"CBT will help me understand and change my thought patterns."
"CBT will cure my anxiety without the need for medication."
"CBT focuses on exploring my childhood experiences."
"CBT will help me avoid situations that make me anxious."
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Correct Answer: A) "CBT will help me understand and change my thought patterns."

Rationale: Cognitive-behavioral therapy helps patients identify and change maladaptive thought patterns that contribute to their anxiety. Understanding this aspect of CBT indicates the patient has a correct understanding of the therapy's purpose.

Reference: American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). (Section on Anxiety Disorders and Treatment Modalities)
125
Incorrect

Correct Answer: A) "CBT will help me understand and change my thought patterns."

Rationale: Cognitive-behavioral therapy helps patients identify and change maladaptive thought patterns that contribute to their anxiety. Understanding this aspect of CBT indicates the patient has a correct understanding of the therapy's purpose.

Reference: American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). (Section on Anxiety Disorders and Treatment Modalities)
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42). A nurse is caring for a client diagnosed with bipolar disorder who is currently in a manic phase. Which of the following nursing interventions is most appropriate?
Encourage participation in group activities.
Provide a low-stimulation environment.
Allow the client to make all decisions independently.
Discourage the client from taking naps during the day.
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Correct Answer: B) Provide a low-stimulation environment.

Rationale: During a manic phase, clients with bipolar disorder benefit from a low-stimulation environment to help reduce agitation and hyperactivity. This intervention promotes a sense of calm and safety.

Reference: Townsend, M. C. (2018). Essentials of Psychiatric Mental Health Nursing: Concepts of Care in Evidence-Based Practice (7th ed.). F.A. Davis Company. (Chapter on Bipolar Disorders)
128
Incorrect

Correct Answer: B) Provide a low-stimulation environment.

Rationale: During a manic phase, clients with bipolar disorder benefit from a low-stimulation environment to help reduce agitation and hyperactivity. This intervention promotes a sense of calm and safety.

Reference: Townsend, M. C. (2018). Essentials of Psychiatric Mental Health Nursing: Concepts of Care in Evidence-Based Practice (7th ed.). F.A. Davis Company. (Chapter on Bipolar Disorders)
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43). A nurse is preparing a care plan for a client who has been diagnosed with post-traumatic stress disorder (PTSD). Which of the following goals is most appropriate for this client?
The client will verbalize understanding of the traumatic event.
The client will avoid situations that trigger memories of the trauma.
The client will develop effective coping strategies for managing anxiety.
The client will express a desire to revisit the site of the traumatic event.
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Correct Answer: C) The client will develop effective coping strategies for managing anxiety.

Rationale: Developing effective coping strategies for managing anxiety is a realistic and therapeutic goal for a client with PTSD. It helps the client handle stress and reduces the impact of anxiety on daily functioning.

Reference: Varcarolis, E. M. (2017). Essentials of Psychiatric Mental Health Nursing: A Communication Approach to Evidence-Based Care (3rd ed.). Elsevier. (Chapter on Trauma and Stressor-Related Disorders)
131
Incorrect

Correct Answer: C) The client will develop effective coping strategies for managing anxiety.

Rationale: Developing effective coping strategies for managing anxiety is a realistic and therapeutic goal for a client with PTSD. It helps the client handle stress and reduces the impact of anxiety on daily functioning.

Reference: Varcarolis, E. M. (2017). Essentials of Psychiatric Mental Health Nursing: A Communication Approach to Evidence-Based Care (3rd ed.). Elsevier. (Chapter on Trauma and Stressor-Related Disorders)
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44). A nurse is conducting an initial assessment of a client with suspected obsessive-compulsive disorder (OCD). Which of the following findings is most characteristic of OCD?
The client experiences sudden, unexpected panic attacks.
The client has persistent, intrusive thoughts and repetitive behaviors.
The client exhibits multiple distinct identities.
The client has a pervasive pattern of distrust and suspiciousness.
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Correct Answer: B) The client has persistent, intrusive thoughts and repetitive behaviors.

Rationale: Obsessive-compulsive disorder is characterized by persistent, intrusive thoughts (obsessions) and repetitive behaviors or mental acts (compulsions) that the individual feels driven to perform.

Reference: American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). (Section on Obsessive-Compulsive and Related Disorders)
134
Incorrect

Correct Answer: B) The client has persistent, intrusive thoughts and repetitive behaviors.

Rationale: Obsessive-compulsive disorder is characterized by persistent, intrusive thoughts (obsessions) and repetitive behaviors or mental acts (compulsions) that the individual feels driven to perform.

Reference: American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). (Section on Obsessive-Compulsive and Related Disorders)
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45). A client with a history of alcohol dependence is admitted to the hospital for detoxification. Which symptoms should the nurse monitor for during the first 48 hours after the client's last drink?
Bradycardia
Hypotension
Seizures
Hpothermia
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Correct Answer: C) Seizures

Rationale: Seizures are a potential complication of alcohol withdrawal, typically occurring within the first 48 hours after cessation. Monitoring and managing withdrawal symptoms are crucial in the care of clients with alcohol dependence.

Reference: Lewis, S. M., Dirksen, S. R., Heitkemper, M. M., Bucher, L., & Harding, M. M. (2014). Medical-Surgical Nursing: Assessment and Management of Clinical Problems (9th ed.). Elsevier. (Chapter on Substance Abuse)
137
INCORRECT

Correct Answer: C) Seizures

Rationale: Seizures are a potential complication of alcohol withdrawal, typically occurring within the first 48 hours after cessation. Monitoring and managing withdrawal symptoms are crucial in the care of clients with alcohol dependence.

Reference: Lewis, S. M., Dirksen, S. R., Heitkemper, M. M., Bucher, L., & Harding, M. M. (2014). Medical-Surgical Nursing: Assessment and Management of Clinical Problems (9th ed.). Elsevier. (Chapter on Substance Abuse)
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46). A nurse is working with a client who has been diagnosed with borderline personality disorder. The client exhibits self-harm behaviors and intense mood swings. Which therapeutic approach is most effective for managing this client's condition?
Cognitive-behavioral therapy
Dialectical behavior therapy
Electroconvulsive therapy
Psychoanalytic therapy
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Correct Answer: B) Dialectical behavior therapy

Rationale: Dialectical behavior therapy (DBT) is particularly effective for clients with borderline personality disorder, focusing on building skills in mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness.

Reference: Townsend, M. C. (2018). Essentials of Psychiatric Mental Health Nursing: Concepts of Care in Evidence-Based Practice (7th ed.). F.A. Davis Company. (Chapter on Personality Disorders)
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INCORRECT

Correct Answer: B) Dialectical behavior therapy

Rationale: Dialectical behavior therapy (DBT) is particularly effective for clients with borderline personality disorder, focusing on building skills in mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness.

Reference: Townsend, M. C. (2018). Essentials of Psychiatric Mental Health Nursing: Concepts of Care in Evidence-Based Practice (7th ed.). F.A. Davis Company. (Chapter on Personality Disorders)
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47). A client diagnosed with anorexia nervosa is admitted to the hospital with severe malnutrition. Which of the following is the priority nursing intervention?
Encourage the client to keep a food diary.
Establish a therapeutic, trusting relationship.
Initiate refeeding and monitor for complications.
Provide education on the importance of nutrition.
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Correct Answer: C) Initiate refeeding and monitor for complications.

Rationale: Initiating refeeding and monitoring for complications, such as refeeding syndrome, is the priority for a client with severe malnutrition. Ensuring the client's physical stability is crucial before addressing psychological issues.

Reference: Lewis, S. M., Dirksen, S. R., Heitkemper, M. M., Bucher, L., & Harding, M. M. (2014). Medical-Surgical Nursing: Assessment and Management of Clinical Problems (9th ed.). Elsevier. (Chapter on Eating Disorders)
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INCORRECT

Correct Answer: C) Initiate refeeding and monitor for complications.

Rationale: Initiating refeeding and monitoring for complications, such as refeeding syndrome, is the priority for a client with severe malnutrition. Ensuring the client's physical stability is crucial before addressing psychological issues.

Reference: Lewis, S. M., Dirksen, S. R., Heitkemper, M. M., Bucher, L., & Harding, M. M. (2014). Medical-Surgical Nursing: Assessment and Management of Clinical Problems (9th ed.). Elsevier. (Chapter on Eating Disorders)
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48). A nurse is caring for a client with post-traumatic stress disorder (PTSD) who frequently experiences flashbacks. Which interventions should the nurse implement to help the client manage these episodes?
Encourage the client to avoid discussing the traumatic event.
Teach the client grounding techniques to use during flashbacks.
Suggest the client watch relaxing television shows to distract from flashbacks.
Instruct the client to rest quietly in a dark room during flashbacks.
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Correct Answer: B) Teach the client grounding techniques to use during flashbacks.

Rationale: Teaching the client grounding techniques can help them manage flashbacks by focusing on the present moment and reducing the intensity of the distressing memories. These techniques are effective in helping clients regain control during flashbacks.

Reference: Varcarolis, E. M. (2017). Essentials of Psychiatric Mental Health Nursing: A Communication Approach to Evidence-Based Care (3rd ed.). Elsevier. (Chapter on Trauma and Stressor-Related Disorders)
146
INCORRECT

Correct Answer: B) Teach the client grounding techniques to use during flashbacks.

Rationale: Teaching the client grounding techniques can help them manage flashbacks by focusing on the present moment and reducing the intensity of the distressing memories. These techniques are effective in helping clients regain control during flashbacks.

Reference: Varcarolis, E. M. (2017). Essentials of Psychiatric Mental Health Nursing: A Communication Approach to Evidence-Based Care (3rd ed.). Elsevier. (Chapter on Trauma and Stressor-Related Disorders)
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49). A nurse is caring for a client diagnosed with generalized anxiety disorder (GAD). Which of the following symptoms is most characteristic of GAD?
Recurring panic attacks
Obsessions and compulsions
Excessive worry about multiple issues
Dissociative episodes
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Correct Answer: C) Excessive worry about multiple issues

Rationale: Generalized anxiety disorder is characterized by excessive, uncontrollable worry about various aspects of daily life. Clients with GAD often find it difficult to control their worry, which can interfere with daily functioning.

Reference: American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). (Section on Anxiety Disorders)
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INCORRECT

Correct Answer: C) Excessive worry about multiple issues

Rationale: Generalized anxiety disorder is characterized by excessive, uncontrollable worry about various aspects of daily life. Clients with GAD often find it difficult to control their worry, which can interfere with daily functioning.

Reference: American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). (Section on Anxiety Disorders)
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50). A client with major depressive disorder is prescribed sertraline (Zoloft). Which of the following should the nurse include in the client’s teaching about this medication?
"You may experience an increase in energy immediately after starting this medication."
"It's important to avoid aged cheese and cured meats while taking this medication."
"It may take several weeks before you start to feel the effects of this medication."
"If you miss a dose, double the next dose to maintain therapeutic levels."
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Correct Answer: C) "It may take several weeks before you start to feel the effects of this medication."

Rationale: Selective serotonin reuptake inhibitors (SSRIs), such as sertraline, often take several weeks to start showing therapeutic effects. Clients should be informed about this delayed onset to manage expectations and encourage adherence to the medication regimen.

Reference: Lewis, S. M., Dirksen, S. R., Heitkemper, M. M., Bucher, L., & Harding, M. M. (2014). Medical-Surgical Nursing: Assessment and Management of Clinical Problems (9th ed.). Elsevier. (Chapter on Psychiatric Nursing Care)
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INCORRECT

Correct Answer: C) "It may take several weeks before you start to feel the effects of this medication."

Rationale: Selective serotonin reuptake inhibitors (SSRIs), such as sertraline, often take several weeks to start showing therapeutic effects. Clients should be informed about this delayed onset to manage expectations and encourage adherence to the medication regimen.

Reference: Lewis, S. M., Dirksen, S. R., Heitkemper, M. M., Bucher, L., & Harding, M. M. (2014). Medical-Surgical Nursing: Assessment and Management of Clinical Problems (9th ed.). Elsevier. (Chapter on Psychiatric Nursing Care)
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Number of Questions
154
Correct Answers
155
Incorrect Answers
156
Percentage
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