NCLEX-PN FINAL 2024-2025 ACTUAL EXAM (VERSION A) REAL EXAM WITH 300+ QUESTIONS AND CORREC, Exams of Nursing

Download NCLEX-PN FINAL 2024-2025 ACTUAL EXAM (VERSION A) REAL EXAM WITH 300+ QUESTIONS AND CORREC and more Exams Nursing in PDF only on Docsity! NCLEX-PN FINAL 2024-2025 ACTUAL EXAM (VERSION A) REAL EXAM WITH 300+ QUESTIONS AND CORRECT ANSWER S (VERIFIED ANSWERS) |ALREADY GRADED A+ NCLEX-PN FINAL 2024-2025 ACTUAL EXAM (VERSION A) REAL EXAM WITH 300+ QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ A nurse is caring for a client with systemic lupus erythematosus (SLE). The client begins to cry and tells the nurse that she is afraid that her skin will be disfigured with lesions. Which intervention does the nurse plan to teach this client to minimize skin infections associated with SLE? Select all that apply. A) Use sunscreen with an SPF of 15 or greater. B) Remain indoors on sunny days. C) Avoid swimming in a pool or the ocean. D) Avoid sun exposure between 10:00 a.m. and 3:00 p.m. E) Decrease sun exposure between 3:00 p.m. and 5:00 p.m. - correct answer Answer: A, D The nurse teaches the client to live a normal life with a few extra precautions. There is a relationship between sun exposure and infection, so the client is taught to use sunscreen with an SPF of at least 15 and to avoid the sun between 10:00 a.m. and 3:00 p.m. The client may swim but should reapply sunscreen after swimming. The client does not need to stay indoors on sunny days or to decrease sun exposure between 3:00 p.m. and 5:00 p.m. A patient on a medical unit has a potassium level of 6.8 mEq/L. What is the priority action that the nurse should take? a. Place the patient on a cardiac monitor. b. Check the patient's BP. c. Instruct the patient to avoid high-potassium foods. d. Call the lab and request a redraw of the lab to verify results. - correct answer a. Dysrhythmias may occur with an elevated potassium level and are potentially lethal. Monitor the rhythm while contacting physician or calling the rapid response team. A patient is admitted to the hospital with CKD. You understand that this condition is characterized by A. Progressive irreversible destruction of the kidneys B. A rapid decrease in urinary output with an elevated BUN level NCLEX-PN FINAL 2024-2025 ACTUAL EXAM (VERSION A) REAL EXAM WITH 300+ QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ B. Monitor for any increase in blood pressure in the affected arm. C. Listen with a stethoscope over the graft for presence of a bruit. D. Frequently monitor the pulses and neurovascular status distal to the graft. - correct answer C. Listen with a stethoscope over the graft for presence of a bruit. A thrill can be felt by palpating the area of anastomosis of the arteriovenous graft, and a bruit can be heard with a stethoscope. The bruit and thrill are created by arterial blood rushing into the vein. What are the main advantages of peritoneal dialysis compared to hemodialysis? A. No medications are required because of the enhanced efficiency of the peritoneal membrane in removing toxins. B. The diet is less restricted and dialysis can be performed at home. C. The dialysate is biocompatible and causes no long-term consequences. D. High glucose concentrations of the dialysate cause a reduction in appetite, promoting weight loss. - correct answer B. The diet is less restricted and dialysis can be performed at home. Advantages of peritoneal dialysis include fewer dietary restrictions and home dialysis is possible. The nurse teaches a client who is recovering from acute kidney disease to avoid which type of medication? A Nonsteroidal anti-inflammatory drugs (NSAIDs) B Angiotensin-converting enzyme (ACE) inhibitors C Opiates D Calcium channel blockers filtration rate and blood flow within the kidney. - correct answer A Nonsteroidal anti-inflammatory drugs (NSAIDs) NCLEX-PN FINAL 2024-2025 ACTUAL EXAM (VERSION A) REAL EXAM WITH 300+ QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ NSAIDs may be nephrotoxic to a client with acute kidney disease, and should be avoided. ACE inhibitors are used for treatment of hypertension and to protect the kidneys, especially in the diabetic client, from progression of kidney disease. Opiates may be used by clients with kidney disease if severe pain is present; however, excretion may be delayed. Calcium channel blockers can improve the glomerular A client with end-stage kidney disease has been put on fluid restrictions. Which assessment finding indicates that the client has not adhered to this restriction? A Blood pressure of 118/78 mm Hg B Weight loss of 3 pounds during hospitalization C Dyspnea and anxiety at rest D Central venous pressure (CVP) of 6 mm Hg - correct answer C Dyspnea and anxiety at rest Dyspnea is a sign of fluid overload and possible pulmonary edema; the nurse should assist the client in correlating symptoms of fluid overload with nonadherence to fluid restriction. Nonadherence to fluid restriction results in fluid volume excess and higher blood pressures; 118/78 mm Hg is a normal blood pressure. Excess fluid intake and fluid retention are manifested by an elevated CVP (>8 mm Hg) and weight gain, not weight loss. Which assessment finding represents a positive response to erythropoietin (Epogen, Procrit) therapy? A Hematocrit of 26.7% B Potassium within normal range C Absence of spontaneous fractures D Less fatigue - correct answer D Less fatigue Treatment of anemia with erythropoietin will result in increased hemoglobin and hematocrit (H&H) and decreased shortness of breath and fatigue. A hematocrit value of 26.7% is low; erythropoietin should restore the hematocrit to at least 36% to be effective. Erythropoietin causes more red blood cells to be produced, increasing H&H, not potassium. Calcium NCLEX-PN FINAL 2024-2025 ACTUAL EXAM (VERSION A) REAL EXAM WITH 300+ QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ supplements and phosphate binders prevent renal osteodystrophy; erythropoietin treats anemia. When caring for a client who receives peritoneal dialysis (PD), which finding does the nurse report to the provider immediately? A Pulse oximetry reading of 95% B Sinus bradycardia, rate of 58 beats/min C Blood pressure of 148/90 mm Hg D Temperature of 101.2° F (38.4° C) - correct answer D Temperature of 101.2° F (38.4° C) Peritonitis is the major complication of PD, caused by intra-abdominal catheter site contamination; meticulous aseptic technique must be used when caring for PD equipment. A pulse oximetry reading of 95% is a normal saturation. Although a heart rate of 58 beats/min is slightly bradycardic, the provider can be informed upon visiting the client. Clients with kidney failure tend to have slightly higher blood pressures due to fluid retention; this is not as serious as a fever. Which clinical manifestation indicates the need for increased fluids in a client with kidney failure? A Increased blood urea nitrogen (BUN) B Increased creatinine level C Pale-colored urine D Decreased sodium level - correct answer A Increased blood urea nitrogen (BUN An increase in BUN can be an indication of dehydration, and an increase in fluids is needed. Increased creatinine indicates kidney impairment. Urine that is pale in color is diluted; an increase in fluids is not necessary. Sodium is increased, not decreased, with dehydration. A client with acute kidney injury is receiving a fluid challenge of 500 mL of normal saline over 1 hour. With a drop factor of 20 drops/mL, how many drops per minute does the nurse infuse? - correct answer 167 drops/min NCLEX-PN FINAL 2024-2025 ACTUAL EXAM (VERSION A) REAL EXAM WITH 300+ QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ D Auscultate the client's lung sounds every 4 hours. E Explain the components of a low-sodium diet. - correct answer A Obtain the client's pre- hemodialysis weight. C Document the amount the client drinks throughout the shift. Obtaining the client's weight and documenting oral fluid intake are routine tasks that can be performed by UAP. Assessment skills (checking the AV fistula and auscultating lung sounds) and client education (explaining special diet) require more education and are in the legal scope of practice of the RN. The LPN/LVN should understand that invasive procedures are postponed for 4 to 6 hours after hemodialysis for which reason? A. The procedure is very tiring. B. Heparin is used during the procedure. C. The patient is disoriented immediately after the procedure. D. The chance of infection is heightened immediately after the procedure. - correct answer B. Heparin is used during the procedure. Invasive procedures are postponed for 4 to 6 hours after dialysis because the clotting time is extended from the heparin used during dialysis and prolonged bleeding could occur. Disorientation of the patient after the procedure is not anticipated. Although the patient may be fatigued after the procedure, this is not the most important reason for avoiding invasive procedures in the period of time immediately after hemodialysis. Infection risk is not increased after dialysis. A patient who has undergone transurethral resection of the prostate (TURP) surgery asks why he needs to have the continuous bladder irrigation (CBI) because it seems to increase his pain. Which explanation would be the best? A. "Normal urine production is maintained until healing can occur." B. "Antibiotics are being instilled into the bladder to prevent infection." C. "The bladder irrigation is necessary to stop the bleeding in the bladder." NCLEX-PN FINAL 2024-2025 ACTUAL EXAM (VERSION A) REAL EXAM WITH 300+ QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ D. "The irrigation is needed to keep the catheter from becoming occluded by blood clots." - correct answer D. "The irrigation is needed to keep the catheter from becoming occluded by blood clots." The continuous irrigation acts to flush small to moderate clots from the GU tract, keeping it patent. CBIs are not used to maintain normal urine production, instill antibiotics into the bladder, or stop bleeding in the bladder. Which statement(s) is/are most accurate regarding transmission of human immunodeficiency virus (HIV) and development of acquired immune deficiency syndrome (AIDS)? (Select all that apply.) A. It is treatable. B. Poor personal hygiene is a factor in its transmission. C. It cannot be transmitted if safer sexual practices are used. D. It enters the bloodstream through breaks in mucous membrane. E. It is a blood-borne pathogen and can be transmitted by contaminated intravenous (IV) drug use supplies. - correct answer A. It is treatable. D. It enters the bloodstream through breaks in mucous membrane. E. It is a blood-borne pathogen and can be transmitted by contaminated intravenous (IV) drug use supplies. HIV/AIDS is a treatable viral infection that enters the body through breaks in mucous membranes (e.g., oral, vaginal, rectal mucosa). Although HIV is a blood-borne pathogen, use of contaminated IV drug use supplies is one of many ways it is transmitted. IV drug use significantly increases the risk of HIV infection. Although risk of infection is considerably lessened by use of safer sex practices, intimate sexual contact involving any mucous membrane will pose a risk of transmission. Personal hygiene has no effect on susceptibility to or transmission of HIV. How is the effectiveness of antiviral drugs administered to treat HIV infection assessed and evaluated? A. Viral load NCLEX-PN FINAL 2024-2025 ACTUAL EXAM (VERSION A) REAL EXAM WITH 300+ QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ B. Megakaryocytes C. Lymphocyte counts D. Red blood cell counts - correct answer A. Viral load All antiretroviral drugs work to reduce the viral load, which is the number of viral RNA copies per milliliter of blood. Which client statement regarding his or her diagnosis of HIV infection indicates a need that further teaching is necessary? A. "I must take these medications exactly as prescribed for the rest of my life." B. "I don't need to use condoms as long as I take my medication as prescribed." C. "I will notify my health care provider immediately if I bruise or bleed more easily than normal." D. "I should remain upright for 30 minutes after taking my zidovudine to prevent esophageal ulceration." - correct answer B. "I don't need to use condoms as long as I take my medication as prescribed." Antiretroviral drugs do not stop the transmission of HIV, and clients need to continue standard precautions and safe sex practice, including condom use. Potential serious adverse effects of zidovudine are bone marrow suppression and esophageal ulceration. A patient known to be positive for HIV is admitted with oral thrush, recurrent vaginal yeast infections, and skin infections. What do these signs indicate? 1. Opportunistic infection 2. Antimicrobial resistance 3. Resistant strain of HIV 4. Sentinel infection - correct answer correct answer : 1 NCLEX-PN FINAL 2024-2025 ACTUAL EXAM (VERSION A) REAL EXAM WITH 300+ QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ 2. Check the urinary catheter tubing for kinks and obstruction. 3. Teach relaxation exercises. 4. Encourage use of patient-controlled analgesia. - correct answer correct answer : 2 Before giving medication, the nurse (2) checks to see that the tubing is not kinked and the catheter is draining well, as obstruction can cause bladder spasm. (1) This is not an initial action. Abdominal distention may be a sign of catheter obstruction as well. (3) Relaxation is not effective to eliminate spasms. (4) The patient who has had a radical procedure may have a patient-controlled analgesia pump to control pain. After giving an injection to a patient with HIV infection, the nurse accidentally receives a needlestick from a too-full needle disposal box. Recommendations for occupational HIV exposure may include the use of which drug(s)? a. didanosine b. lamivudine and enfuvirtide c. emtricitabine and tenofovir d. acyclovir - correct answer C The nurse is reviewing the use of multidrug therapy for HIV with a patient. Which statements are correct regarding the reason for using multiple drugs to treat HIV? (Select all that apply.) a. The combination of drugs has fewer associated toxicities. b. The use of multiple drugs is more effective against resistant strains of HIV. NCLEX-PN FINAL 2024-2025 ACTUAL EXAM (VERSION A) REAL EXAM WITH 300+ QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ c. Effective treatment results in reduced T-cell counts. d. The goal of this treatment is to reduce the viral load. e. This type of therapy reduces the incidence of opportunistic infections. - correct answer B, D, E The order for a patient who has a severe case of shingles is for acyclovir (Zovirax) 10 mg/kg IV every 8 hours for 7 days. The patient weighs 165 pounds. How much is each dose? - correct answer 750 mg per dose A patient with acute renal injury has a GFR (glomerular filtration rate) of 40 mL/min. Which signs and symptoms below may this patient present with? Select all that apply: A. Hypervolemia B. Hypokalemia C. Increased BUN level D. Decreased Creatinine level - correct answer The answers are A and C. The glomerular filtration rate indicates how well the glomerulus is filtering the blood. A normal GFR tends to be 90 mL/min or higher. A GFR of 40 mL/min indicates that the kidney's ability to filter the blood is decreased. Therefore, the kidneys will be unable to remove waste and excessive water from the blood...hence hypervolemia and an increased BUN level will present in this patient. The patient will experience HYPERkalemia (not hypo) because the kidneys are unable to remove potassium from the blood. In addition, an INCREASED creatinine level (not decreased) will present because the kidneys cannot remove excessive waste products, such as creatinine. You're assessing morning lab values on a female patient who is recovering from a myocardial infraction. Which lab value below requires you to notify the physician? A. Potassium level 4.2 mEq/L B. Creatinine clearance 35 mL/min NCLEX-PN FINAL 2024-2025 ACTUAL EXAM (VERSION A) REAL EXAM WITH 300+ QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ C. BUN 20 mg/dL D. Blood pH 7.40 - correct answer The answer is B. A normal creatinine clearance level in a female should be 85-125 mL/min (95-140 mL/min males). A creatinine clearance level indicates the amount of blood the kidneys can make per minute that contain no amounts of creatinine in it. Remember creatinine is a waste product of muscle breakdown. Therefore, the kidneys should be able to remove excessive amounts of it from the bloodstream. A patient who has experienced a myocardial infraction is at risk for pre- renal acute injury due to decreased cardiac output to the kidneys from a damaged heart muscle (the heart isn't able to pump as efficiently because of ischemia). All the other labs values are normal. A 55 year old male patient is admitted with a massive GI bleed. The patient is at risk for what type of acute kidney injury? A. Post-renal B. Intra-renal C. Pre-renal D. Intrinsic renal - correct answer The answer is C. Pre-renal injury is due to decreased perfusion to the kidneys secondary to a cause (massive GI bleeding...patient is losing blood volume). This leads to a major decrease in kidney function because the kidneys are deprived of nutrients to function and the amount of blood it can filter. Pre-renal injury can eventually lead to intrarenal damage where the nephrons become damaged. Select all the patients below that are at risk for acute intra-renal injury? A. A 45 year old male with a renal calculus. B. A 65 year old male with benign prostatic hyperplasia. C. A 25 year old female receiving chemotherapy. D. A 36 year old female with renal artery stenosis. E. A 6 year old male with acute glomerulonephritis. NCLEX-PN FINAL 2024-2025 ACTUAL EXAM (VERSION A) REAL EXAM WITH 300+ QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ D. Hyperkalemia - correct answer The answer is B. EPO (erythropoietin) helps create red blood cells in the bone marrow. The kidneys produce EPO and when the kidneys are damaged in CKD they can decrease in the production of EPO. Therefore, the patient is at risk for anemia. A 65 year old male patient has a glomerular filtration rate of 55 mL/min. The patient has a history of uncontrolled hypertension and coronary artery disease. You're assessing the new medication orders received for this patient. Which medication ordered by the physician will help treat the patient's hypertension along with providing a protective mechanism to the kidneys? A. Lisinopril B. Metoprolol C. Amlodipine D. Verapamil - correct answer The answer is A. There are two types of drugs that can be used to treat hypertension and protect the kidneys in patients with CKD. These drugs include angiotensin converting enzyme inhibitors (ACE inhibitors) and angiotensin receptor blockers (ARBs). The only drug listed here that is correct is Lisinopril. This drug is known as an ACE inhibitor. Metoprolol is a BETA BLOCKER. Amlodipine and Verapamil are calcium channel blockers. A patient with Stage 5 CKD is experiencing extreme pruritus and has several areas of crystallized white deposits on the skin. As the nurse, you know this is due to excessive amounts of what substance found in the blood? A. Calcium B. Urea C. Phosphate D. Erythropoietin - correct answer The answer is B. NCLEX-PN FINAL 2024-2025 ACTUAL EXAM (VERSION A) REAL EXAM WITH 300+ QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ This patient is experiencing uremic frost that occurs in severe chronic kidney disease. This is due to high amounts of urea in the blood being secreted via the sweat glands onto the skin, which will appear as white deposits on the skin. The patient will experience itching with this as well. Your patient with chronic kidney disease is scheduled for dialysis in the morning. While examining the patient's telemetry strip, you note tall peaked T-waves. You notify the physician who orders a STAT basic metabolic panel (BMP). What result from the BMP confirms the EKG abnormality? A. Phosphate 3.2 mg/dL B. Calcium 9.3 mg/dL C. Magnesium 2.2 mg/dL D. Potassium 7.1 mEq/L - correct answer The answer is D. The patient's potassium level is extremely elevated. A normal potassium level is 3.5-5.1 mEq/L. This patient is experiencing hyperkalemia, which can cause tall peak T-waves. Remember in CKD (especially prior to dialysis), the patient will experience electrolyte imbalances, especially hyperkalemia. A patient with stage 4 chronic kidney disease asks what type of diet they should follow. You explain the patient should follow a: A. Low protein, low sodium, low potassium, low phosphate diet B. High protein, low sodium, low potassium, high phosphate diet C. Low protein, high sodium, high potassium, high phosphate diet D. Low protein, low sodium, low potassium, high phosphate diet - correct answer The answer is A. The patient should follow this type of diet because protein breaks down into urea (remember patients will have increased urea levels), low sodium to prevent fluid retention, low potassium to prevent hyperkalemia (remember glomerulus isn't filtering out potassium/phosphate as it should), and low phosphate to prevent hyperphosphatemia. The kidneys are responsible for performing all the following functions EXCEPT? NCLEX-PN FINAL 2024-2025 ACTUAL EXAM (VERSION A) REAL EXAM WITH 300+ QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ A. Activating Vitamin D B. Secreting Renin C. Secreting Erythropoietin D. Maintaining cortisol production - correct answer The answer is D. The adrenal glands are responsible for maintaining cortisol production not the kidneys. You're providing an in-service to a group of nurses about the different types of kidney stones. You explain to the attendees that the most common type of kidney stone is made up of: A. Cholesterol B. Calcium and oxalate C. Calcium and phosphate D. Uric acid - correct answer The answer is B. The most common type of kidney stone composite is calcium and oxalate. Which patient below is at MOST risk for developing uric acid type kidney stones? A. A 53 year old female with recurrent urinary tract infections. B. A 6 year old male with cystinuria. C. A 63 year male with gout. D. A 25 year old female that follows a vegan diet and report eating high amounts of spinach and strawberries on a regular basis. - correct answer The answer is C. Patients with gout experience high uric acid levels which can lead to the development of uric acid kidney stones. In option A, the patient is at risk for struvite kidney stones. In option B, the patient is at risk for cystine kidney stones, and in option C, the patient is at a small risk for calcium oxalate stones due to the high consumption of foods with oxalates. You're providing care to a patient with a uric acid kidney stone that is 2 mm in size per diagnostic imaging. The patient is having severe pain and rates their pain 10 on 1-10 scale. The NCLEX-PN FINAL 2024-2025 ACTUAL EXAM (VERSION A) REAL EXAM WITH 300+ QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ 2. Strain urine at home regularly. 3. Eliminate dairy products from the diet. 4. Follow measures to alkalinize the urine. - correct answer 1. A high daily fluid intake is essential for all clients who are at risk for calculi formation because it prevents urinary stasis and concentration, which can cause crystallization. Depending on the composition of the stone, the client also may be instructed to institute specific dietary measures aimed at preventing stone formation. Clients may need to limit purine, calcium, or oxalate. Urine may need to be either alkaline or acid. There is no need to strain urine regularly. During hemodialysis, the patient develops light-headedness and nausea. What should the nurse do first? a. Administer hypertonic saline. b. Administer a blood transfusion. c. Decrease the rate of fluid removal. d. Administer antiemetic medications. - correct answer c. Decrease the rate of fluid removal. The patient is experiencing hypotension from a rapid removal of vascular volume. The rate and volume of fluid removal will be decreased, and 0.9% saline solution may be infused. Hypertonic saline is not used because of the high sodium load. A blood transfusion is not indicated. Antiemetic medications may help the nausea but would not help the hypovolemia. The patient has rapidly progressing glomerular inflammation. Weight has increased and urine output is steadily declining. What is the priority nursing intervention? a. Monitor the patient's cardiac status. b. Teach the patient about hand washing. c. Obtain a serum specimen for electrolytes. d. Increase direct observation of the patient. - correct answer a. Monitor the patient's cardiac status. NCLEX-PN FINAL 2024-2025 ACTUAL EXAM (VERSION A) REAL EXAM WITH 300+ QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ The nurse's priority is to monitor the patient's cardiac status. With the rapidly progressing glomerulonephritis, renal function begins to fail and fluid, potassium, and hydrogen retention lead to hypervolemia, hyperkalemia, and metabolic acidosis. Excess fluid increases the workload of the heart, and hyperkalemia can lead to life-threatening dysrhythmias. Teaching about hand washing and observation of the patient are important nursing interventions but are not the priority. Electrolyte measurement is a collaborative intervention that will be done as ordered by the health care provider. A 78-yr-old patient has stage 3 CKD and is being taught about a low-potassium diet. The nurse knows the patient understands the diet when the patient selects which foods to eat? a. Apple, green beans, and a roast beef sandwich b. Granola made with dried fruits, nuts, and seeds c. Watermelon and ice cream with chocolate sauce d. Bran cereal with ½ banana and milk and orange juice - correct answer a. Apple, green beans, and a roast beef sandwich When the patient selects an apple, green beans, and a roast beef sandwich, the patient demonstrates understanding of the low-potassium diet. Granola, dried fruits, nuts and seeds, milk products, chocolate sauce, bran cereal, banana, and orange juice all have elevated levels of potassium, at or above 200 mg per 1/2 cup. Which assessment findings would alert the nurse that the patient has entered the diuretic phase of acute kidney injury (AKI)? Select all that apply. a. Dehydration b. Hypokalemia c. Hypernatremia d. BUN increases e. Urine output increases f. Serum creatinine increases - correct answer a. Dehydration b. Hypokalemia NCLEX-PN FINAL 2024-2025 ACTUAL EXAM (VERSION A) REAL EXAM WITH 300+ QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ e. Urine output increases The hallmark of entering the diuretic phase is the production of copious amounts of urine. Dehydration, hypokalemia, and hyponatremia occur in the diuretic phase of AKI because the nephrons can excrete wastes but not concentrate urine. Serum BUN and serum creatinine levels begin to decrease. A patient with a 25-year history of type 1 diabetes mellitus is reporting fatigue, edema, and an irregular heartbeat. On assessment, the nurse notes newly developed hypertension and uncontrolled blood sugars. Which diagnostic study is most indicative of chronic kidney disease (CKD)? a. Serum creatinine b. Serum potassium c. Microalbuminuria d. Calculated glomerular filtration rate (GFR) - correct answer d. Calculated glomerular filtration rate (GFR) The best study to determine kidney function or CKD that would be expected in the patient with diabetes is the calculated GFR that is obtained from the patient's age, gender, race, and serum creatinine. It would need to be abnormal for 3 months to establish a diagnosis of CKD. A creatinine clearance test done with a blood sample and a 24-hour urine collection is also important. Serum creatinine is not the best test for CKD because the level varies with different patients. Serum potassium levels could explain why the patient has an irregular heartbeat. The finding of microalbuminuria can alert the patient with diabetes about potential renal involvement and potentially failing kidneys. However, urine albumin levels are not used for diagnosis of CKD. The home care nurse visits a 34-yr-old woman receiving peritoneal dialysis. Which statement indicates a need for immediate follow-up by the nurse? a. "Drain time is faster if I rub my abdomen." b. "The fluid draining from the catheter is cloudy." c. "The drainage is bloody when I have my period." NCLEX-PN FINAL 2024-2025 ACTUAL EXAM (VERSION A) REAL EXAM WITH 300+ QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ should not exceed 12. Fatigue is treated with this medication. Iron supplementation, ferric gluconate, is often ordered alongside erythropoietin to provide an adequate response. You are administering erythropoietin to the patient with CKF. Which of the following would be a sign of adverse reaction? SATA A) Seizure B) Hypertension C) Decreased u/o D) Improved exercise tolerance E) Headache - correct answer Answer: A, B, and E. Seizures, Hypertension, HA, arthralgia, nausea, increased clotting of vascular access sites, seizures, and depletion of body iron stores are adverse effects of administering erythropoietin. Decreased u/o is a symptom of the disease process. Improved exercise tolerance would be a benefit of this medication. The patient undergoing peritoneal dialysis complains of abdominal pain. The nurse notes the drainage to be cloudy. She also palpates rebound tenderness. Which complication does the nurse suspect? A) Leakage around catheter B) Internal Bleeding C) Hypertriglycerdemia D) Peritonitis - correct answer Answer: D. Peritonitis is the most serious complication of PD. It's symtpoms include rebound tendernece, cloudy drainage, low grade fever, abdominal pain, and rebound tenderness. The patient with ESRD arrives to the clinic ready for his peritoneal dialysis. He says "I am not very happy about being here today" This patient has a history of severe hypertension, heart failure, pulmonary edema, diabetes, A-fib, hyperlipidemia, CAD and has recently been diagnosed with osteoporosis. His vitals today are BP 145/70, HR 99, T 99.7 O2 94%. Which piece of patient data does the nurse need to pay most attention to right before beginning dialysis? NCLEX-PN FINAL 2024-2025 ACTUAL EXAM (VERSION A) REAL EXAM WITH 300+ QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ A) The patient's anxiety B) Hx of diabetes C) BP 145/70 D) Hx of A-fib - correct answer Answer: B. It is important for the nurse to closely monitor the patient's glucose level because peritoneal dialysis uses solutions containing glucose. Insulin will probably need to be administered The nurse is taking care of the patient with chronic kidney disease. Which of the following meal trays would be the best for this patient? A) Whole grain roll with baked chicken and pea soup and milk B) Sandwich with smoked salmon lunchmeat, green beans, and banana pudding C) Baked ham, mashed potatoes, tomato soup and peanut butter cookies D) Low-sodium chicken noodle soup, apple slices, white-wheat roll, and rice - correct answer Answer: D. This tray contains a small amount of protein and an adequate amount of carbohydrates that are low in sodium and potassium. Although a whole-grain roll would be appropriate with baked chicken. Pea soup and the milk would be high in potassium and protein. Smoked meats are often high in sodium. Tomato soup and peanut butter would add extra potassium and protein to this patient's diet A patient who has tested positive for the human immunodeficiency virus (HIV) arrives at the clinic with a report of fever, nonproductive cough, and fatigue. The patient's CD4 count is 184 cells/mcL. How should the healthcare provider interpret these findings? Please choose from one of the following options. A. The patient is diagnosed with acquired immunodeficiency syndrome (AIDS). B.The patient is now in the latent stages of HIV infection NCLEX-PN FINAL 2024-2025 ACTUAL EXAM (VERSION A) REAL EXAM WITH 300+ QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ C.These findings provide evidence that the patient has seroconverted. D. This is an expected finding because the patient has tested positive for HIV. - correct answer A. The patient is diagnosed with acquired immunodeficiency syndrome (AIDS). A client with acquired immunodeficiency syndrome (AIDS) has a nursing diagnosis of Imbalanced nutrition: less than body requirements. The nurse plans which of the following goals with this client? a) consume foods and beverages that are high in glucose b) plan large menus and cook meals in advance c) eat low-calorie snacks between meals d) eat small, frequent meals throughout the day - correct answer D The client should eat small, frequent meals throughout the day. The client also should take in nutrient-dense and high-calorie meals and snacks rather than those that are high in glucose only. The client is encouraged to eat favorite foods to keep intake up and plan meals that are easy to prepare. The client can also avoid taking fluids with meals to increase food intake before satiety sets in. A client who was tested for human immunodeficiency virus (HIV) after a recent exposure had a negative result. During the post-test counseling session, the nurse tells the client which of the following? a) the test should be repeated in 6 months b) this ensures that the client is not infected with the HIV virus c) the client no longer needs to protect himself from sexual partners NCLEX-PN FINAL 2024-2025 ACTUAL EXAM (VERSION A) REAL EXAM WITH 300+ QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ C. Increased secretions of digestive juices D. Decreased gastrointestinal absorption - correct answer B Often the complications of the acquired immunodeficiency syndrome (AIDS) have a negative impact on nutritional status. Weight loss and protein depletion are commonly seen among the AIDS population. The nurse observes precaution in caring for Mr. X as HIV is most easily transmitted in: a. Vaginal secretions and urine b. Breast milk and tears c. Feces and saliva d. Blood and semen - correct answer Answer D. Keyword: MOST EASILY. Rationale: HIV is MOST EASILY transmitted in blood, semen and vaginal secretions. However, it has been noted to be found in fecal materials, urine, saliva, tears and breast milk. Nurse Jaja is giving an injection to Ms. X. After giving an injection, the nurse accidentally stuck her finger with the needle when the client became very agitated. To determine if the nurse became infected with HIV when is the best time to test her for HIV antibodies? a. Immediately and repeat the test after 12 weeks b. Immediately and repeat the test after 4 weeks c. After a week and repeat the test in 4 months d. After a weeks and repeat the test in 6 months - correct answer Answer A. Keyword: BEST TIME. Rationale: To determine if a preexisting infection is present a test should be done immediately and is repeated again in 3 months time (12 weeks) to detect seroconversion as a result of the needle stick. The woman is afraid she may get HIV from her bisexual husband. What should the nurse include when teaching her about preexposure prophylaxis (select all that apply)? NCLEX-PN FINAL 2024-2025 ACTUAL EXAM (VERSION A) REAL EXAM WITH 300+ QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ A. Take fluconazole (Diflucan). B. Take amphotericin B (Fungizone). C. Use condoms for risk-reducing sexual relations. D. Take emtricitabine and tenofovir (Truvada) regularly. E. Have regular HIV testing for herself and her husband. - correct answer C. Use condoms for risk-reducing sexual relations. D. Take emtricitabine and tenofovir (Truvada) regularly. E. Have regular HIV testing for herself and her husband. Using male or female condoms, having monthly HIV testing for the patient and her husband, and the woman taking emtricitabine and tenofovir regularly has shown to decrease the infection of heterosexual women having sex with a partner who participates in high-risk behavior. Fluconazole and amphotericin B are taken for Candida albicans, Coccidioides immitis, and Cryptococcosus neoformans, which are all opportunistic diseases associate with HIV infection The nurse was accidently stuck with a needle used on an HIV-positive patient. After reporting this, what care should this nurse first receive? A. Personal protective equipment B. Combination antiretroviral therapy NCLEX-PN FINAL 2024-2025 ACTUAL EXAM (VERSION A) REAL EXAM WITH 300+ QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ C. Counseling to report blood exposures D. A negative evaluation by the manage - correct answer B. Combination antiretroviral therapy Postexposure prophylaxis with combination antiretroviral therapy can significantly decrease the risk of infection. Personal protective equipment should be available although it may not have stopped this needle stick. The needle stick has been reported. The negative evaluation may or may not be needed but would not occur first. The HIV-infected patient is taught health promotion activities including good nutrition; avoiding alcohol, tobacco, drug use, and exposure to infectious agents; keeping up to date with vaccines; getting adequate rest; and stress management. What is the rationale behind these interventions that the nurse knows? A. Delaying disease progression B. Preventing disease transmission C. Helping to cure the HIV infection D. Enabling an increase in self-care activities - correct answer A. Delaying disease progression These health promotion activities along with mental health counseling, support groups, and a therapeutic relationship with health care providers will promote a healthy immune system, which may delay disease progression. These measures will not cure HIV infection, prevent disease transmission, or increase self-care activities During HIV infection a. the virus replicates mainly in B-cells before spreading to CD4+ T cells. b. infection of monocytes may occur, but antibodies quickly destroy these cells. NCLEX-PN FINAL 2024-2025 ACTUAL EXAM (VERSION A) REAL EXAM WITH 300+ QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ d. Standard precautions - correct answer d. Standard precautions Standard precautions are indicated for prevention of transmission of HIV to the health care worker. HIV is not transmitted by casual contact or respiratory droplets. HIV may be transmitted through sexual intercourse with an infected partner, exposure to HIV-infected blood or blood products, and perinatal transmission during pregnancy, at delivery, or though breastfeeding. A 52-year-old female patient was exposed to human immunodeficiency virus (HIV) 2 weeks ago through sharing needles with other substance users. What symptoms will the nurse teach the patient to report that would indicate the patient has developed an acute HIV infection? a. Cough, diarrhea, headaches, blurred vision, muscle fatigue b. Night sweats, fatigue, fever, and persistent generalized lymphadenopathy c. Oropharyngeal candidiasis or thrush, vaginal candidal infection, or oral or genital herpes d. Flu-like symptoms such as fever, sore throat, swollen lymph glands, nausea, or diarrhea - correct answer d. Flu-like symptoms such as fever, sore throat, swollen lymph glands, nausea, or diarrhea Clinical manifestations of an acute infection with HIV include flu-like symptoms between 2 to 4 weeks after exposure. Early chronic HIV infection clinical manifestations are either asymptomatic or include fatigue, headache, low-grade fever, night sweats, and persistent generalized lympadenopathy. Intermediate chronic HIV infection clinical manifestations include candidal infections, shingles, oral or genital herpes, bacterial infections, Kaposi sarcoma, or oral hairy leukoplakia. Late chronic HIV infection or acquired immunodeficiency syndrome (AIDS) includes opportunistic diseases (infections and cancer). A client is suspected of having hepatitis. Which diagnostic test result will assist in confirming this diagnosis ? A.Elevate hemoglobin level NCLEX-PN FINAL 2024-2025 ACTUAL EXAM (VERSION A) REAL EXAM WITH 300+ QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ B. Elevated serum bilirubin level C. Elevated blood urea nitrogen level D. Decreased erythrocyte sedimentation rate - correct answer correct answer B Laboratory indicator of hepatitis include elevated liver enzyme levels, elevated serum bilirubin levels.Thinking about the organ that is involved in hepatitis should assist in directing to choose option B liver function test. To prevent the spread of hepatitis A virus, the nurse is especially careful when A. Disposing of food trays B. Emptying bed pans C. Taking an oral temperature D. Changing IV - correct answer B HAV is transmitted primarily person-to-person by the fecal-oral route. Food can be a method of transmission but needs to be fecally contaminated. Since the transmission of hepatitis A is fecal-oral and not saliva or blood like hepatitis B, taking a temperature and changing IV tubing would not spread hepatitis A. Which type of hepatitis is transmitted by the fecal-oral route via contaminated food, water, or direct contact with an infected person? 1. Hepatitis A 2. Hepatitis B 3. Hepatitis C 4. Hepatitis D - correct answer correct answer : 1 NCLEX-PN FINAL 2024-2025 ACTUAL EXAM (VERSION A) REAL EXAM WITH 300+ QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ Rationale: 1. The hepatitis A virus is in the stool of infected people for up to 2 weeks before symptoms develop 2. Hepatitis B is spread through contact with infected blood and body fluids 3. Hepatitis C is transmitted through contact with infected blood and body fluids 4. Hepatitis D infection only causes infection in people who are also infected with Hepatitis B or C The nurse sticks herself with a dirty needle. Which action should the nurse implement first? 1.Notify the infection control nurse. 2.Cleanse the area with soap and water. 3.Request post-exposure prophylaxis. 4.Check the hepatitis status of the client. - correct answer Answer 2. The nurse should first clean the needle stick with soap and water to help remove any virus that is on the skin A client has developed hepatitis A after eating contaminated oysters. The nurse assesses the client for which of the following? 1. Malaise 2. Dark stools 3. Weight gain 4. Left upper quadrant discomfort - correct answer correct answer 1 Rationale: Hepatitis causes GI symptoms such as anorexia, nausea, right upper quadrant discomfort and weight loss. Fatigue and malaise are common. Stools will be light or clay colored if conjugated bilirubin is unable to flow out of the liver because of inflammation or obstruction of the bile ducts. What type of precaution should the nurse implement to protect from being exposed to any of the hepatitis viruses? NCLEX-PN FINAL 2024-2025 ACTUAL EXAM (VERSION A) REAL EXAM WITH 300+ QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ The nurse instructs a client diagnosed with hepatitis A about untoward signs and symptoms related to hepatitis that may develop. The one that should be reported to the practitioner is: 1)Fatigue 2)Anorexia 3)Yellow urine 4)Clay-covered stools - correct answer Correct 4 Clay-colored stools are indicative of hepatic obstruction because bile is prevented from entering the intestines. Which statement by the client diagnosed with hepatitis warrants immediate intervention by the clinic nurse? 1) I will not drink any type of beer or mixed drink. 2)I will get adequate rest so I don't get exhausted. 3) I had a big hearty breakfast this morning. 4) I took some cough syrup for this nasty head cold. - correct answer Answer 4: Rationale: 1) The client should avoid all alcohol to prevent further liver damage and promote healing. 2) Rest is needed for healing of the liver and to promote optimum immune function. 3) Clients with hepatitis need increased caloric intake so this is a good statement. 4)The client needs to understand some types of cough syrup have alcohol and all alcohol must be avoided to prevent further injury to the liver; therefore, this statement requires intervention" A health care provider who has not been immunized for hepatitis B is exposed to the hepatitis B virus (HBV) through a needle stick from an infected patient. The infection control nurse informs the individual that treatment for the exposure should include: NCLEX-PN FINAL 2024-2025 ACTUAL EXAM (VERSION A) REAL EXAM WITH 300+ QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ a. baseline hepatitis B antibody testing now and in 2 months. b. active immunization with hepatitis B vaccine. c. hepatitis B immune globulin (HBIG) injection. d. both the hepatitis B vaccine and HBIG injection. - correct answer Correct D The recommended treatment for exposure to hepatitis B in unvaccinated individuals is to receive both HBIG and the hepatitis B vaccine, which would provide temporary passive immunity and promote active immunity. Antibody testing may also be done, but this would not provide protection from the exposure. To determine the severity of the symptoms for a patient with benign prostatic hyperplasia (BPH), the nurse will ask the patient about a. blood in the urine. b. lower back or hip pain. c. erectile dysfunction (ED). d. strength of the urinary stream. - correct answer ANS: D The American Urological Association (AUA) Symptom Index for a patient with BPH asks questions about the force and frequency of urination, nocturia, etc. Blood in the urine, ED, and back or hip pain are not typical symptoms of BPH. A patient scheduled for a transurethral resection of the prostate (TURP) for BPH tells the nurse that he has delayed having surgery because he is afraid it will affect his sexual function. When responding to his concern, the nurse explains that a. with this type of surgery, erectile problems are rare, but retrograde ejaculation may occur. b. information about penile implants used for ED is available if he is interested. c. there are many methods of sexual expression that can be alternatives to sexual intercourse. NCLEX-PN FINAL 2024-2025 ACTUAL EXAM (VERSION A) REAL EXAM WITH 300+ QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ d. sterility will not be a problem after surgery because sperm production will not be affected. - correct answer Answer: A Rationale: Erectile problems are rare, but retrograde ejaculation may occur after TURP. Erectile function is not usually affected by a TURP, so the patient will not need information about penile implants or reassurance that other forms of sexual expression may be used. Because the patient has not asked about fertility, reassurance about sperm production does not address his concerns. The wife of a patient who has undergone a TURP and has continuous bladder irrigation asks the nurse about the purpose of the continuous bladder irrigation. Which response by the nurse is appropriate? a. "The bladder irrigation is needed to stop the postoperative bleeding in the bladder." b. "The irrigation is needed to keep the catheter from being occluded by blood clots." c. "Normal production of urine is maintained with the irrigations until healing occurs." d. "Antibiotics are being administered into the bladder with the irrigation solution." - correct answer Answer: B Rationale: The purpose of bladder irrigation is to remove clots from the bladder and to prevent obstruction of the catheter by clots. The irrigation does not decrease bleeding or maintain urine production. Antibiotics are given by the IV route, not through the bladder irrigation. What are intrarenal causes of AKI (select all that apply)? a. anaphylaxis b. renal stones c. bladder cancer d. nephrotoxic drugs NCLEX-PN FINAL 2024-2025 ACTUAL EXAM (VERSION A) REAL EXAM WITH 300+ QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ A patient is being discharged home for treatment of hypothyroidism. Which medication is most commonly prescribed for this condition? A. Tapazole B. PTU (Propylthiouracil) C. Synthroid D. Inderal - correct answer C. Synthroid is the only medication listed that treats hypothyroidism. All the other medications are used for hyperthyroidism. You are performing discharge teaching with a patient who is going home on Synthroid. Which statement by the patient causes you to re-educate the patient about this medication? A. "I will take this medication at bedtime with a snack." B. "I will never stop taking the medication abruptly." C. "If I have palpitations, chest pain, intolerance to heat, or feel restless, I will notify the doctor." D. "I will not take this medication at the same time I take my Carafate." - correct answer A. "I will take this medication at bedtime with a snack." Synthroid is best taken in the MORNING on an empty stomach. All the other statements are correct about taking Synthroid. A patient is admitted with complaints of palpations, excessive sweating, and unable to tolerate heat. In addition, the patient voices concern about how her appearance has changed over the past year. The patient presents with protruding eyeballs and pretibial myxedema on the legs and feet. Which of the following is the likely cause of the patient's signs and symptoms? NCLEX-PN FINAL 2024-2025 ACTUAL EXAM (VERSION A) REAL EXAM WITH 300+ QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ A. Thyroiditis B. Deficiency of iodine consumption C. Grave's Disease D. Hypothyroidism - correct answer C. Grave's Disease A patient who is in her first trimester of pregnancy is diagnosed with hyperthyroidism. Which medication do you suspect the patient will be started on? A. Propylthiouracil (PTU) B. Radioactive Iodine C. Tapazole D. Synthroid - correct answer A. Propylthiouracil (PTU) Propylthiouracil (PTU) is the only anti-thyroid medication that can be used during the 1st trimester of pregnancy. Which of the following are treatment options for hyperthyroidism? Please select all that apply: A. Thyroidectomy B. Methimazole C. Liothyronine Sodium "Cytomel" NCLEX-PN FINAL 2024-2025 ACTUAL EXAM (VERSION A) REAL EXAM WITH 300+ QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ D. Radioactive Iodine - correct answer The answers are A, B,and D. Liothyronine Sodium "Cytomel" is a treatment for hypothyroidism. All the other options are for hyperthyroidism. A patient was recently discharged home for treatment of hypothyroidism and was ordered to take Synthroid for treatment. The patient is re-admitted with signs and symptoms of the following: heart rate 42, blood pressure 70/56, blood glucose 55, and body temperature of 96.8 'F. The patient is very fatigued and drowsy. The family reports the patient has not been taking Synthroid since being discharged home from the hospital. Which of the following conditions is this patient most likely experiencing? A. Thryoid Storm B. Myxedema Coma C. Iodism D. Toxic Nodular Goiter - correct answer B. Myxedema Coma The red flags in this question are the patient's signs/symptoms and the report from the family the patient hasn't been taking the prescribed Synthroid. The patient is showing signs and symptoms of extreme hypothyroidism known as Myxedema coma (which is life-threatening if not treated). A patient is 6 hours post-opt from a thyroidectomy. The surgical site is clean, dry and intact with no excessive swelling noted. What position is best for this patient to be in? A. Fowler's B. Prone C. Trendelenburg NCLEX-PN FINAL 2024-2025 ACTUAL EXAM (VERSION A) REAL EXAM WITH 300+ QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ D. Fresh salad with chopped water chestnuts - correct answer The answer is A. Patients who are experiencing hepatic encephalopathy are having issues with toxin build up in the body, specifically ammonia. Remember that ammonia is the byproduct of protein breakdown, and normally the liver can take the ammonia from the protein breakdown and turn it into urea (but if the cirrhosis is severe enough this can't happen). Therefore, the patient should consume foods LOW in protein until the encephalopathy subsides. Option A is very high in protein while the others are low in protein. Remember meats, legumes, eggs, broccoli rabe, certain grains etc. are high in protein. During your morning assessment of a patient with cirrhosis, you note the patient is disoriented to person and place. In addition while assessing the upper extremities, the patient's hands demonstrate a flapping motion. What lab result would explain these abnormal assessment findings? A. Decreased magnesium level B. Increased calcium level C. Increased ammonia level D. Increased creatinine level - correct answer The answer is C. Based on the assessment findings and the fact the patient has cirrhosis, the patient is experiencing hepatic encephalopathy. This is due to the buildup of toxins in the blood, specifically ammonia. The flapping motion of the hands is called "asterixis". Therefore, an increased ammonia level would confirm these abnormal assessment findings. You are receiving shift report on a patient with cirrhosis. The nurse tells you the patient's bilirubin levels are very high. Based on this, what assessment findings may you expect to find during your head-to-toe assessment? Select all that apply: A. Frothy light-colored urine B. Dark brown urine C. Yellowing of the sclera D. Dark brown stool NCLEX-PN FINAL 2024-2025 ACTUAL EXAM (VERSION A) REAL EXAM WITH 300+ QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ E. Jaundice of the skin F. Bluish mucous membranes - correct answer The answers are B, C, and E. High bilirubin levels are because the hepatocytes are no longer able to properly conjugate the bilirubin because they are damaged. This causes bilirubin to leak into the blood and urine (rather than entering the bile and being excreted in the stool). Therefore, the bilirubin stays in the blood and will enter the urine. This will cause the patient to experience yellowing of the skin, sclera of the eyes, and mucous membranes ("jaundice") and have dark brown urine. The stools would be CLAY-COLORED not dark brown (remember bilirubin normally gives stool it brown color but it will be absent). Which of the following is NOT a role of the liver? A. Removing hormones from the body B. Producing bile C. Absorbing water D. Producing albumin - correct answer The answer is C. The liver does not absorb water. The intestines are responsible for this function. You're caring for a 45 year old patient who is admitted with suspected acute pancreatitis. The patient reports having extreme mid-epigastric pain that radiates to the back. The patient states the pain started last night after eating fast food. As the nurse, you know the two most common causes of acute pancreatitis are A. High cholesterol and alcohol abuse B. History of diabetes and smoking C. Pancreatic cancer and obesity NCLEX-PN FINAL 2024-2025 ACTUAL EXAM (VERSION A) REAL EXAM WITH 300+ QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ D. Gallstones and alcohol abuse - correct answer The answer is D. Main causes of acute pancreatitis are gallstones and alcohol consumption. Heavy, long-term alcohol abuse is the main cause of CHRONIC pancreatitis. While assisting a patient with chronic pancreatitis to the bathroom, you note the patient's stool to be oily/greasy in appearance. In your documentation you note this as: A. Steatorrhea B. Melena C. Currant D. Hematochezia - correct answer The answer is A. Steatorrhea is an oily/greasy appearance of the stool which can occur in chronic pancreatitis. This occurs due to the inability of the pancreas to produce digestive enzymes which help break down fats. Fats are not being broken down; therefore, it is being excreted into the stool. Melena is used to describe tarry/black stool, hematochezia is used to describe red stools, and currant are jelly type stools. A patient with acute pancreatitis is reporting excessive thirst, excessive voiding, and blurred vision. As the nurse, it is priority you? A. Reassure the patient this is normal with pancreatitis B. Check the patient's blood glucose C. Assist the patient with drinking a simple sugar drink like orange juice NCLEX-PN FINAL 2024-2025 ACTUAL EXAM (VERSION A) REAL EXAM WITH 300+ QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ 3. promotes comfort and rest. 4. prevents the formation of blood clots. - correct answer correct answer : 2 (2) Keeping the neck in midline ensures proper drainage of fluids from the head; preventing excessive hip flexion seems to prevent increased intracranial pressure. (1) A neutral position is not necessarily recommended. (3) The midline position may not be comfortable for the patient. (4) The midline position does not prevent formation of blood clots. The surgeon inserts an intraventricular catheter into the lateral ventricle of a patient with increased ICP. When asked by a relative about the procedure, an accurate response by the nurse would be: 1. "The catheter allows direct visualization of the brain tissue." 2. "The catheter is used to monitor brain waves." 3. "The catheter is used to remove excess fluid inside the brain." 4. "The catheter is used to infuse fluids and medications into the brain." - correct answer correct answer : 3 (3) An intraventricular catheter is used to drain off excess cerebral spinal fluid. (1) The catheter does not allow visualization of the brain tissue. (2) The catheter does not have a mechanism to monitor brain waves. (4). Fluids and medications are not infused into the brain through the intraventricular catheter. Which patient is the nurse most concerned with developing a subdural hematoma following an injury that resulted with a blow to the head? A. The 76-year-old patient who is taking an anticoagulant NCLEX-PN FINAL 2024-2025 ACTUAL EXAM (VERSION A) REAL EXAM WITH 300+ QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ B. The 16-year-old football player who suffered a concussion C. The 36-year-old patient who has a history of migraine headaches D. The 56-year-old patient who is taking an antihypertensive medication - correct answer A. The 76-year-old patient who is taking an anticoagulant A subdural hematoma results when blood leaks under the dura mater (subdural) and presses against the softer arachnoid membrane and the brain tissue it is covering. As blood leaks, the hematoma grows in size. The 76-year-old patient is most at risk for a subdural hematoma due to his anticoagulant medication. The football player who suffered a concussion is at an increased risk for a head bleed, but less so than the elderly patient taking anticoagulant medication. The patients with migraine headaches and antihypertensive medications are not at an increased risk for hemorrhage. After a head injury, the patient begins to have drainage from the nose. The nurse assesses the drainage by which method? A. Halo test B. Tinel sign C. Battle sign D. Babinski sign - correct answer A. Halo test The halo test is used to determine whether drainage from the nose or ear is cerebrospinal fluid. Tinel sign is one assessment used during the assessment of carpal tunnel symptoms. Bruising behind the ear that occurs after a head injury is called Battle sign. Babinski sign is checked as part of a neurologic assessment. A patient is bought in by ambulance with a suspected brain injury. What are the outward symptoms of head injury? (Select all that apply.) NCLEX-PN FINAL 2024-2025 ACTUAL EXAM (VERSION A) REAL EXAM WITH 300+ QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ A. Tinnitus B. Diarrhea C. Ottorhea D. Battle sign - correct answer A, C, D The outward symptoms of head injury include tinnitus, ottorhea, and Battle sign. Diarrhea is not a symptom of head injury. There are two types of tumors: benign and malignant. A difference between the two types is: 1. malignant cells have a nucleus that is small and regular in shape, whereas benign cells are large and irregular. 2. malignant cells do not know when to stop multiplying, whereas benign cells have controlled patterns of reproduction and follow signals to stop. 3. malignant cells do not invade adjacent tissue, whereas benign cells sometimes do. 4. malignant cells reproduce exact copies, whereas benign cells become more disorganized with each succeeding generation. - correct answer correct answer : 2 One of the characteristics of malignant cells is that they become more and more undifferentiated as the malignancy progresses. The nucleus becomes large and irregular and they lose the trait of stopping reproduction upon command. (1) Malignant cells have a large nucleus. (3) Malignant cells can invade adjacent cells. (4) Benign cells are organized and malignant cells disorganized. A nurse is reviewing medication orders for a female patient with SLE who is positive for the presence of antiphospholipid antibodies. The nurse would seek clarification from the provider about which type of medication? NCLEX-PN FINAL 2024-2025 ACTUAL EXAM (VERSION A) REAL EXAM WITH 300+ QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ B. There is poor circulation within the veins. C. They are no longer able to produce vitamin K. D. There is an accumulation of ammonia in the blood. - correct answer C. They are no longer able to produce vitamin K. Esophageal varices are engorged veins (similar to varicose veins) that line the esophagus. They are the result of portal congestion and hypertension. The congestion can lead to massive bleeding when the vein walls rupture from increased pressure or esophageal irritation. Another factor in hemorrhage is that the liver is no longer able to make vitamin K. Ammonia buildup does not increase the patient's risk for hemorrhage. When planning care for the patient with acute pancreatitis, the LPN/LVN knows that which intervention is a priority of care? A. Pain control B. Nutritional supplementation C. Observation for mental changes D. Observation for intestinal obstruction - correct answer A. Pain control The patient with acute pancreatitis presents with pain. The intervention having the highest priority involves management of the pain. Nutritional supplementation and observation for mental changes and intestinal obstruction are appropriate interventions, but not the ones of highest importance. The nurse is caring for a patient with late-stage cirrhosis. The nurse considers which factor when participating in a patient care conference? NCLEX-PN FINAL 2024-2025 ACTUAL EXAM (VERSION A) REAL EXAM WITH 300+ QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ A. Late-stage cirrhosis is irreversible. B. Late-stage cirrhosis can be managed with lifestyle changes. C. Late-stage cirrhosis can be cured with lactulose and spironolactone. D. Late-stage cirrhosis is characterized by periods of remission alternating with flare-ups. - correct answer A. Late-stage cirrhosis is irreversible. After cirrhosis reaches the late stage, it is irreversible. Lactulose is used to manage ammonia levels and hepatic encephalopathy, but it is not curative. Cirrhosis does not have remission periods. A 57-year-old man is admitted with a diagnosis of cirrhosis. The nurse is aware that he will most likely require which intervention(s)? (Select all that apply.) A. Diuretics B. Increased fluids C. Bleeding precautions D. Vegetable-based proteins E. Lactulose administration - correct answer A, C, D, E Because the liver produces clotting factors and is now dysfunctional, risk for bleeding exists. The liver cannot metabolize proteins, especially albumin, properly. This leads to edema and ascites and requires diuretics, preferably potassium wasting. Ammonia buildup is likely; lactulose binds with this toxic metabolic by-product and allows for its excretion through the GI tract. Patients with liver disorders are at high risk for fluid volume excess. In the postoperative period, the LPN/LVN should observe a patient who has had a thyroidectomy for which signs of thyroid crisis? NCLEX-PN FINAL 2024-2025 ACTUAL EXAM (VERSION A) REAL EXAM WITH 300+ QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ A. Depression and fatigue B. Respiratory distress and hoarseness C. Twitching of muscles and severe convulsions D. Extreme temperature elevation and rapid pulse rate - correct answer D. Extreme temperature elevation and rapid pulse rate Thyroid storm (TS), also known as thyroid crisis or thyrotoxicosis, is another complication following a thyroidectomy. In the postoperative setting, the condition is caused by a sudden increase in the output of thyroxine caused by manipulation of the thyroid as it is being removed. Another cause of TS may be improper reduction of thyroid secretions before surgery. The symptoms of TS are produced by a sudden and extreme elevation of all body processes. The temperature may rise to 106° F (41.1° C) or more, the pulse increases to as much as 200 beats/min, respirations become rapid, and the patient exhibits marked apprehension and restlessness. Unless the condition is relieved, the patient quickly passes from delirium to coma to death from heart failure. Respiratory distress is a complication of thyroidectomy if the edema affects the airway, but it is not a sign of thyroid storm. Muscle twitching and convulsions are a sign of hypocalcemia from hyperparathyroidism. Hoarseness is an expected finding following thyroidectomy. Depression and fatigue may result from hypothyroidism. The patient presents to the clinic with a gross enlargement of the anterior neck. The nurse knows that this is most likely caused by a deficiency in which substance? A. Iodine B. Sodium C. Calcium NCLEX-PN FINAL 2024-2025 ACTUAL EXAM (VERSION A) REAL EXAM WITH 300+ QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ 3. Increase in pulse 4. Difficulty swallowing 5. Difficulty breathing - correct answer correct answer s: 1, 3, 4, 5 Watch for signs of bleeding and swelling at the operative area. Any rise in temperature, pulse, or respiration rate should be reported immediately, as it may indicate a high level of thyroxine in the bloodstream. External swelling may cause constriction of the bandage around the neck. Difficulty in swallowing or breathing also should be reported immediately, as it may indicate internal edema and pressure on the esophagus and trachea. There would be no reason for the patient to be hypothermic. The nurse is reviewing the medications that each of her patients will receive during the shift. Which patient is likely to receive levothyroxine? 1. Patient who has von Recklinghausen disease 2. Patient who has hypothyroidism 3. Patient who has hyponatremia 4. Patient who has Graves disease - correct answer correct answer : 2 Levothyroxine is given to patients with hypothyroidism. Von Recklinghausen disease is hyperparathyroidism. Treatment may include infusion of isotonic sodium chloride and diuretic agents, phosphate therapy, and administration of calcitonin to decrease the rate of skeletal calcium release, or surgical removal of a major portion of the parathyroids. The underlying cause of hyponatremia must be determined, but fluid restriction and diuretics could be ordered if fluid overload is present. Graves' disease is a type of hyperthyroidism that may be treated with antithyroid drugs or radioactive iodine. NCLEX-PN FINAL 2024-2025 ACTUAL EXAM (VERSION A) REAL EXAM WITH 300+ QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ A nurse provides patient instructions regarding taking iodine preparations. It is important for the nurse to include which instruction(s)? (Select all that apply.) 1. "Dilute the preparations well." 2. "Use a straw to prevent staining of the teeth." 3. "Watch for easy bruising." 4. "Report severe epigastric pain." 5. "Anticipate a metallic taste." - correct answer correct answer s: 1, 2, 4, 5 Iodine preparations should be given well-diluted and administered through a straw, as they can stain the teeth. Adverse effects of iodine preparations can include gastrointestinal upset, metallic taste, skin rashes, allergic reactions, and epigastric pain. Iodine does not cause bruising. When monitoring the laboratory values for a patient who is taking antithyroid drugs, the nurse knows to watch for a. increased platelet counts. b. increased white blood cell counts. c. increased blood urea nitrogen level. d. increased blood glucose levels. - correct answer c. increased blood urea nitrogen level. NCLEX-PN FINAL 2024-2025 ACTUAL EXAM (VERSION A) REAL EXAM WITH 300+ QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ The pharmacy has called a patient to notify her that the current brand of thyroid replacement hormone is on back order. The patient calls the clinic to ask what to do. Which is the best response by the nurse? a. "Go ahead and take the other brand that the pharmacy has available for now." b. "You can stop the medication until your current brand is available." c. "You can split the thyroid pills that you have left so that they will last longer." d. "Let me ask your prescriber what needs to be done; we will need to watch how you do if you switch brands." - correct answer d. "Let me ask your prescriber what needs to be done; we will need to watch how you do if you switch brands." The nurse is teaching a patient who has a new prescription for the antithyroid drug propylthiouracil (PTU). Which statement by the nurse is correct? a. "There are no food restrictions while on this drug." b. "You need to avoid foods high in iodine, such as iodized salt, seafood, and soy products." c. "This drug is given to raise the thyroid hormone levels in your blood." d. "Take this drug in the morning on an empty stomach." - correct answer b. "You need to avoid foods high in iodine, such as iodized salt, seafood, and soy products." Which statement by the patient indicates an understanding of discharge instructions given by the nurse about the newly prescribed medication levothyroxine (Synthroid)? A. "I will take a double dose to make up for the missed one." NCLEX-PN FINAL 2024-2025 ACTUAL EXAM (VERSION A) REAL EXAM WITH 300+ QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ B. Eggs C. Chicken D. Seafood - correct answer D. Seafood Seafood contains high amounts of iodine. The other choices do not. The health care provider orders lactulose for a patient with hepatic encephalopathy. The nurse will monitor for effectiveness of this medication for this patient by assessing what? A. Relief of constipation B. Relief of abdominal pain C. Decreased liver enzymes D. Decreased ammonia levels - correct answer D. Decreased ammonia levels Hepatic encephalopathy is a complication of liver disease and is associated with elevated serum ammonia levels. Lactulose traps ammonia in the intestinal tract. Its laxative effect then expels the ammonia from the colon, resulting in decreased serum ammonia levels and correction of hepatic encephalopathy. When planning care for a patient with cirrhosis, the nurse will give highest priority to which nursing diagnosis? A. Impaired skin integrity related to edema, ascites, and pruritus B. Imbalanced nutrition: less than body requirements related to anorexia NCLEX-PN FINAL 2024-2025 ACTUAL EXAM (VERSION A) REAL EXAM WITH 300+ QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ C. Excess fluid volume related to portal hypertension and hyperaldosteronism D. Ineffective breathing pattern related to pressure on diaphragm and reduced lung volume - correct answer D. Ineffective breathing pattern related to pressure on diaphragm and reduced lung volume Although all of these nursing diagnoses are appropriate and important in the care of a patient with cirrhosis, airway and breathing are always the highest priorities. When caring for a patient with liver disease, the nurse recognizes the need to prevent bleeding resulting from altered clotting factors and rupture of varices. Which nursing interventions would be appropriate to achieve this outcome (select all that apply)? A. Use smallest gauge needle possible when giving injections or drawing blood. B. Teach patient to avoid straining at stool, vigorous blowing of nose, and coughing. C. Advise patient to use soft-bristle toothbrush and avoid ingestion of irritating food. D. Apply gentle pressure for the shortest possible time period after performing venipuncture. E. Instruct patient to avoid aspirin and NSAIDs to prevent hemorrhage when varices are present. - correct answer A, B, C, E A. Use smallest gauge needle possible when giving injections or drawing blood. B. Teach patient to avoid straining at stool, vigorous blowing of nose, and coughing. C. Advise patient to use soft-bristle toothbrush and avoid ingestion of irritating food. NCLEX-PN FINAL 2024-2025 ACTUAL EXAM (VERSION A) REAL EXAM WITH 300+ QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ E. Instruct patient to avoid aspirin and NSAIDs to prevent hemorrhage when varices are present. Using the smallest gauge needle for injections will minimize the risk of bleeding into the tissues. Avoiding straining, nose blowing, and coughing will reduce the risk of hemorrhage at these sites. The use of a soft-bristle toothbrush and avoidance of irritating food will reduce injury to highly vascular mucous membranes. The nurse should apply gentle but prolonged pressure to venipuncture sites to minimize the risk of bleeding. Aspirin and NSAIDs should not be used in patients with liver disease because they interfere with platelet aggregation, thus increasing the risk for bleeding. The patient with cirrhosis has an increased abdominal girth from ascites. The nurse should know that this fluid gathers in the abdomen for which reasons (select all that apply)? A. There is decreased colloid oncotic pressure from the liver's inability to synthesize albumin. B. Hyperaldosteronism related to damaged hepatocytes increases sodium and fluid retention. C. Portal hypertension pushes proteins from the blood vessels, causing leaking into the peritoneal cavity. D. Osmoreceptors in the hypothalamus stimulate thirst, which causes the stimulation to take in fluids orally. E. Overactivity of the enlarged spleen results in increased removal of blood cells from the circulation, which decreases the vascular pressure. - correct answer A, B, C A. There is decreased colloid oncotic pressure from the liver's inability to synthesize albumin. B. Hyperaldosteronism related to damaged hepatocytes increases sodium and fluid retention. NCLEX-PN FINAL 2024-2025 ACTUAL EXAM (VERSION A) REAL EXAM WITH 300+ QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ marked abdominal distention. Areas of cyanosis or greenish to yellow-brown discoloration of the abdominal wall may occur. Other areas of ecchymoses are the flanks (Grey Turner's spots or sign, a bluish flank discoloration) and the periumbilical area (Cullen's sign, a bluish periumbilical discoloration). The patient with advanced cirrhosis asks why his abdomen is so swollen. The nurse's response is based on the knowledge that a. a lack of clotting factors promotes the collection of blood in the abdominal cavity. b. portal hypertension and hypoalbuminemia cause a fluid shift into the peritoneal space. c. decreased peristalsis in the GI tract contributes to gas formation and distention of the bowel. d. bile salts in the blood irritate the peritoneal membranes, causing edema and pocketing of fluid. - correct answer correct answer : b Rationale: Ascites is the accumulation of serous fluid in the peritoneal or abdominal cavity and is a common manifestation of cirrhosis. With portal hypertension, proteins shift from the blood vessels through the larger pores of the sinusoids (capillaries) into the lymph space. When the lymphatic system is unable to carry off the excess proteins and water, those substances leak through the liver capsule into the peritoneal cavity. Osmotic pressure of the proteins pulls additional fluid into the peritoneal cavity. A second mechanism of ascites formation is hypoalbuminemia, which results from the inability of the liver to synthesize albumin. Hypoalbuminemia results in decreased colloidal oncotic pressure. A third mechanism is hyperaldosteronism, which occurs when aldosterone is not metabolized by damaged hepatocytes. The increased level of aldosterone causes increases in sodium reabsorption by the renal tubules. Sodium retention and an increase in antidiuretic hormone levels cause additional water retention. The client diagnosed with hypothyroidism is prescribed the thyroid hormone levothyroxine (Synthroid). Which assessment data indicate the medication has been effective? 1. The client has a three (3)-pound weight gain. NCLEX-PN FINAL 2024-2025 ACTUAL EXAM (VERSION A) REAL EXAM WITH 300+ QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ 2. The client has a decreased pulse rate. 3. The client's temperature is WNL. 4. The client denies any diaphoresis. - correct answer 3.The client with hypothyroidism frequently has a subnormal temperature,so a temperature WNL indicates the medication is effective. 1. The medication will help increase the client's metabolic rate. A weight gain indicates not enough medication is being taken to put the client in a euthyroid (normal thyroid) state. 2. A decreased pulse rate indicates there is not enough thyroid hormone level; therefore, the medication is not effective. 4. Diaphoresis (sweating) occurs with hyper-thyroidism, not hypothyroidism Which signs/symptoms should make the nurse suspect the client is experiencing a thyroid storm? 1. Obstipation and hypoactive bowel sounds. 2. Hyperpyrexia and extreme tachycardia. 3. Hypotension and bradycardia. 4. Decreased respirations and hypoxia. - correct answer 2. Hyperpyrexia (high fever) and heart rate above 130 beats per minute are signs of thyroid storm, a severely exaggerated hyperthyroidism. NCLEX-PN FINAL 2024-2025 ACTUAL EXAM (VERSION A) REAL EXAM WITH 300+ QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ 1. These are signs of myxedema (hypothyroidism) coma. Obstipation is extreme constipation. 3. Decreased blood pressure and slow heartrate are signs of myxedema coma. 4. These are signs/symptoms of myxedema coma. The nurse is preparing a client with a new diagnosis of hypothyroidism for discharge. The nurse determines that the client understands discharge instructions if the client states that which symptoms are associated with this diagnosis? Select all that apply. 1.Tremors 2.Weight loss 3.Feeling cold 4.Loss of body hair 5.Persistent lethargy 6.Puffiness of the face - correct answer 3, 4, 5, 6 A client has been diagnosed with hyperthyroidism. Which signs and symptoms may indicate thyroid storm, a complication of this disorder? Select all that apply. 1.Fever 2.Nausea 3.Lethargy 4.Tremors 5.Confusion 6.Bradycardia - correct answer 1, 2, 4, 5 Thyroid storm is an acute and life-threatening condition that occurs in a client with uncontrollable hyperthyroidism. Symptoms of thyroid storm include elevated temperature (fever), nausea, and tremors. In addition, as the condition progresses, the client becomes confused. The client is restless and anxious and experiences tachycardia. A nurse is completing the admission assessment of a client who has acute pancreatitis. Which finding is the first priority? NCLEX-PN FINAL 2024-2025 ACTUAL EXAM (VERSION A) REAL EXAM WITH 300+ QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ Rationale: Serum amylase levels increase within two to 12 hours of the onset of acute pancreatitis; lipase elevates and remains elevated for seven to 14 days The client is diagnosed with acute pancreatitis. What health-care provider's admitting order should the nurse question? A. Bedrest with bathroom privileges B. Initiate IV therapy of D5W at 125 mL/hr C. Weight client daily D. Low fat, low carb diet - correct answer D. carbs are the easiest for the body to digest Rationale: Bedrest decreases the metabolic rate. The client should be NPO to rest the pancreas to decrease the auto digestion of the pancreas. Since the client is NPO IV therapy is appropriate. Weight changes will happen as a result of diet and IV fluids therefore daily weights is appropriate. The client diagnosed with acute pancreatitis is in pain. Which position should the nurse assist the client to assume to help decrease the pain? A. Recommend lying in the prone position with legs extended B. Maintain a tripod position over the bedside table C. Place in side-lying position with knees flexed D. Encourage a supine position with a pillow under the knees - correct answer C NCLEX-PN FINAL 2024-2025 ACTUAL EXAM (VERSION A) REAL EXAM WITH 300+ QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ Rationale: The fetal position deceases pain caused by the stretching of the peritoneum as a result of edema. The pancreas is located abdomen. Anything that causes the abdomen to be stretched will increase pain. A family member asks the nurse to explain the purpose of hospice care. Which of the following is the best response? Hospice care: 1) Is appropriate when the patient desires to intentionally end his life 2) Focuses on minimizing the disease process as rapidly as possible 3) Focuses on symptom management for patients not responding to treatment 4) Is holistic care for patients dying or debilitated and not expected to improve - correct answer 4) Is holistic care for patients dying or debilitated and not expected to improve Rationale: Hospice care focuses on holistic care of patients actively dying or not expected to improve. It helps patients face death with dignity and comfort. Euthanasia refers to the deliberate ending of a life. Palliative care is aggressively planned care that manages symptoms of patients whose disease process no longer responds to treatment. Aggressive medical treatment is aimed at stopping the disease process. The nurse is reviewing the lab results for a pt with cirrhosis and notes that the ammonia level is elevated. Which diet does the nurse anticipate to be prescribed for this pt? 1. Low-protein 2. High-protein 3. Moderate-fat NCLEX-PN FINAL 2024-2025 ACTUAL EXAM (VERSION A) REAL EXAM WITH 300+ QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ 4.High-carb - correct answer 1. Low-protein diet Protein provided by the diet is transported to the liver via the portal vein. The liver breaks down protein, which results in the formation of ammonia. The client enters the outpatient clinic and states to the triage nurse, "I think I have the flu. I'm so tired, I have no appetite, and everything hurts." The triage nurse assesses the client and finds a butterfly rash over the bridge of nose and on the cheeks. Which diagnosis does the nurse expect? A) Systemic lupus erythematosus B) Influenza type A C) Pnemonia D) Shingles - correct answer Answer: A The rash over the nose and cheeks is sometimes called a butterfly rash and is classic for the diagnosis of systemic lupus erythematosus (SLE), although not every client diagnosed with this disorder will have this rash. A nurse is caring for a client with systemic lupus erythematous (SLE) who is taking hydroxychloroquine (Plaquenil). The nurse understands that the primary concern with this drug is: A) Pulmonary fibrosis. B) Cushingoid effects. C) Retinal toxicity. NCLEX-PN FINAL 2024-2025 ACTUAL EXAM (VERSION A) REAL EXAM WITH 300+ QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ A ~ Blueberries B ~ Green beans C ~ Bacon D ~ Baked fish E ~ Fried potatoes - correct answer C ~ Bacon E ~ Fried potatoes These are fatty foods A patient who is to have a growth in her breast removed says to the LPN/LVN, "How are benign tumors different from cancerous ones?" Which response by the nurse is most accurate? A. "Benign tumor cells replicate faster than cancerous cells." B. "Benign tumor cells tend to spread easier than cancerous tumor cells." C. "Cancerous tumor cells have changes in the DNA." D. "Cancerous tumors are usually encapsulated." - correct answer C. Cancerous cells have changes to the DNA, replicate much faster than benign cells, and have the ability to spread to other tissues. Benign tumors are generally encapsulated. A patient who has been prescribed an antineoplastic drug for his newly diagnosed cancer asks the nurse what the most common side effect is for these drugs. What is the nurse's most accurate response? A. "These drugs almost always cause a vitamin B12 deficiency." B. "Gastrointestinal (GI) upset is the most common side effect." NCLEX-PN FINAL 2024-2025 ACTUAL EXAM (VERSION A) REAL EXAM WITH 300+ QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ C. "An elevated temperature is a common side effect." D. "Most of these drugs cause some degree of bone marrow depression." - correct answer D. All antineoplastic drugs cause bone marrow depression. The degree of bone marrow depression depends on the drug and dosage. GI upset is experienced with some neoplastic drugs. An elevated temperature is a sign of infection, and vitamin B A patient is scheduled to receive external radiation therapy. Which potential side effects should the nurse include in patient teaching points? Select all that apply. A ~ Skin reaction at site of exposure B ~ Loss of appetite C ~ Mental slowness D ~ Fatigue E ~ Potential contamination to others - correct answer A, B, D, ~ External radiation therapy has far fewer side effects than in the past but does include skin reaction, loss of appetite, and fatigue. Mental slowness is not a side effect of external radiation therapy. Contamination to others can occur with internal radiation therapy. A patient who is near death has the following nursing diagnosis: Impaired gas exchange related to fluid in the lungs. Which of these interventions is most appropriate? A ~ Maintain patient in a side-lying position. B ~ Suction the patient as needed. C ~ Teach the patient how to do pursed-lip breathing. D ~ Encourage the patient to cough and deep-breathe at least every 3 hours. - correct answer A ~ A side-lying position will help prevent aspiration of mucus and fluids produced during the dying process. Suctioning is uncomfortable and will stimulate more mucus and fluid production NCLEX-PN FINAL 2024-2025 ACTUAL EXAM (VERSION A) REAL EXAM WITH 300+ QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ by irritating the mucosa. Pursed-lip breathing and coughing will not decrease the mucus and fluid production and would be exhausting to the dying patient. A patient with a diagnosis of lung cancer is told that there is metastasis of the disease. Which statement by the patient indicates an understanding of his current condition? A ~ "Metastasis means that like cells have joined together into a mass." B ~ "Metastasis means that there is stabilization of a group of cells in one site." C ~ "Metastasis means that there is movement of cells from one part of my body to another part of my body." D ~ "Metastasis means that there has been an invasion of malignant cells into multiple normal body tissues simultaneously." - correct answer C ~ Metastasis occurs when cancer cells have moved from one part of the body to another site in the body. Which medication does the nurse plan to administer to a client before chemotherapy to decrease the incidence of nausea? A. Morphine B. Ondansetron (Zofran) C. Naloxone (Narcan) D. Diazepam (Valium) - correct answer B. Ondansetron (Zofran) Rationale A. Morphine is a narcotic analgesic or opiate; it may cause nausea. NCLEX-PN FINAL 2024-2025 ACTUAL EXAM (VERSION A) REAL EXAM WITH 300+ QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ B. He is more responsive, a sign that he may be improving C. His pupils are fixed and dilated, an ominous sign D. He does not move or make sounds, which may mean he got too much pain medication - correct answer A. He is less responsive, a sign that his intracranial pressure may be increasing The nurse is assessing the client with a traumatic brain injury after a skateboarding accident. Which symptom is the nurse most concerned about? A. Amnesia for events of accident B. Bleeding head laceration C. Pupil changes in one eye D. Restlessness and confusion - correct answer C. Pupil changes in one eye The client has a traumatic brain injury from a motor vehicle accident. Which sign does the nurse associate with increased intracranial pressure (ICP)? A. Changes in breathing pattern B. Dizziness when sitting up C. Increasing level of consciousness D. Equal and reactive pupils - correct answer A. Changes in breathing pattern A client has fluid leaking from the nose after a basilar skull fracture. Which of the following would indicate that the fluid is cerebrospinal fluid? NCLEX-PN FINAL 2024-2025 ACTUAL EXAM (VERSION A) REAL EXAM WITH 300+ QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ A. It clumps together on the paper and has a pH of 7 B. It leaves a yellowish ring on the paper and tests positive for glucose. C. It is grossly bloody in appearance and has a pH of 6. D. It is clear in appearance and tests negative for glucose. - correct answer B. It leaves a yellowish ring on the paper and tests positive for glucose. This is often called the "halo" sign True or false, in clients with closed head injury, a lumbar puncture is necessary to assess for presence of blood in the cerebral spinal fluid (CSF)? - correct answer False A client is admitted to ICU from PACU after craniotomy to remove a clot in the frontal lobe. How will the nurse position the client? A. With flexed knees to decrease intra-abdominal pressure B. On the right side to prevent bleeding at incision site C. With head of bed elevated at least 30 degrees to promote venous drainage D. Log rolled to bed and head of bed no more than 15 degrees elevation - correct answer C. With head of bed elevated at least 30 degrees to promote venous drainage The nurse is monitoring the client with ↑intracranial pressure (ICP). Which of the following does the nurse expect to be ordered to maintain the ICP within a specified range? A. Dexamethasone (Decadron) B. Hydrochlorothiazide (HydroDIURIL) NCLEX-PN FINAL 2024-2025 ACTUAL EXAM (VERSION A) REAL EXAM WITH 300+ QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ C. Mannitol (Osmitrol) D. Phenytoin (Dilantin) - correct answer C. Mannitol (Osmitrol) The nurse administers intravenous mannitol for an unconscious client. A decrease in which of the following is expected as a therapeutic effect of this drug? A. Seizure activity B. Cerebral edema C. Cerebral metabolism D. Cerebral inflammation - correct answer B. Cerebral edema Which of the following nursing diagnoses are most appropriate for the client who has an intraventricular catheter for intracranial pressure monitoring? A. Risk for fluid volume excess related to infusion into ventricle B. Risk for altered skin integrity related to need to remain in supine position C. Risk for infection related to catheter inserted into ventricle D. Pain related to wound in scalp for insertion of monitoring device - correct answer C. Risk for infection related to catheter inserted into ventricle A 41-year-old patient who is unconscious has a nursing diagnosis of ineffective cerebral tissue perfusion related to cerebral tissue swelling. Which nursing intervention will be included in the plan of care? a. Encourage coughing and deep breathing.