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Questions 227

NCLEX-PN

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Extract:


Question 1 of 5

When explaining Standard Precautions to a client, the nurse should explain that the primary purpose of Standard Precautions is to:

Correct Answer: D

Rationale: Standard Precautions aim to reduce disease transmission (e.g., via blood, body fluids) for all patients, encompassing but not limited to AIDS or nosocomial infections.

Extract:

Which of the following clinical conditions exacerbates electrolyte excretion?


Question 2 of 5

Nasogastric feedings

Correct Answer: B

Rationale: Surgical drains remove fluid and electrolytes, exacerbating excretion.

Extract:


Question 3 of 5

A client comes to the emergency department complaining of headache, malaise, chills, fever, and a stiff neck. Vital sign assessment reveals a temperature elevation, increased heart and respiratory rates, and normal blood pressure. On physical examination, the nurse notes confusion, a petechial rash, nuchal rigidity, Brudzinski's sign, and Kernig's sign. What does Brudzinski's sign indicate?

Correct Answer: D

Rationale: Brudzinski's sign indicates meningeal irritation, as in meningitis. Other signs of meningeal irritation include nuchal rigidity and Kernig's sign. Brudzinski's sign doesn't indicate increased ICP, cerebral edema, or low CSF pressure.

Question 4 of 5

The physician prescribes penicillin potassium oral suspension 56 mg/kg/day in four divided doses for a client with anorexia nervosa who weighs 25 kg. The medication dispensed by the pharmacy contains a dosage strength of 125 mg/5 ml. How many milliliters of solution should the nurse administer with each dose?

Correct Answer: A

Rationale:
To determine the total daily dosage, set up the following proportion: 25 kg/X = 1 kg/56 mg, X = 1,400 mg. Next, divide the daily dosage by four doses to determine the dose to administer every 6 hours: X = 1,400 mg/4 doses, X = 350 mg/dose. The adolescent should receive 350 mg every 6 hours. Lastly, calculate the volume to give for each dose by setting up this proportion: X/350 mg = 5 ml/125 mg, X = 14 ml.

Extract:

Immunity by antibody formation during the course of a disease is:


Question 5 of 5

Active natural immunity.

Correct Answer: A

Rationale: In active natural immunity, the infected person's immune system responds to the invading organism by producing antibodies specific for the invader.

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