NCLEX PN

Correct Answers:

A. Client with iron deficiency anemia takes iron supplements with milk

D. Client taking metronidazole mentions going to a wine-tasting party tonight

E. Client with closed-angle glaucoma takes over-the-counter diphenhydramine for a cold

Correct Answer Explanations:

A. Client with iron deficiency anemia takes iron supplements with milk

Iron supplements should not be taken with milk, as the calcium in milk binds with iron and reduces its absorption. This can make the iron supplement less effective, prolonging or worsening the client’s anemia. The nurse should instruct the client to take iron with water or a vitamin C source (like orange juice) to enhance absorption.

D. Client taking metronidazole mentions going to a wine-tasting party tonight

Metronidazole can cause a serious disulfiram-like reaction when combined with alcohol. Even small amounts of alcohol can result in flushing, tachycardia, nausea, vomiting, and hypotension. The nurse must intervene to prevent a dangerous interaction by advising the client to avoid alcohol during therapy and for at least 48 hours after the last dose.

E. Client with closed-angle glaucoma takes over-the-counter diphenhydramine for a cold

Diphenhydramine is an antihistamine with anticholinergic properties that can increase intraocular pressure. This can be dangerous for clients with closed-angle glaucoma, potentially triggering an acute attack. The nurse should educate the client to avoid medications with anticholinergic effects and consult their provider for safer alternatives.

Correct Answers:

A. 22-year-old man with a head injury sustained during a college football game

C. 56-year-old man 2 weeks post myocardial infarction

E. 74-year-old man with portal hypertension related to alcohol-induced cirrhosis

F. 82-year-old woman 1 week post cataract surgery

Explanation of Correct Answers:

A. 22-year-old man with a head injury sustained during a college football game

The Valsalva maneuver can increase intracranial pressure, which is dangerous for a client with a recent or healing head injury. Avoiding straining during defecation reduces the risk of further elevating intracranial pressure and potential complications such as brain herniation or worsened cerebral edema.

C. 56-year-old man 2 weeks post myocardial infarction

The Valsalva maneuver causes increased intrathoracic pressure, which can reduce venous return and provoke arrhythmias or ischemia in post-MI clients. These clients should avoid straining to prevent vagal stimulation, which can lead to bradycardia or cardiovascular collapse.

E. 74-year-old man with portal hypertension related to alcohol-induced cirrhosis

Increased intra-abdominal pressure from straining can worsen portal hypertension and increase the risk of rupturing esophageal varices. This could lead to life-threatening bleeding. Preventing constipation and avoiding the Valsalva maneuver is essential for this population.

F. 82-year-old woman 1 week post cataract surgery

Increased intraocular pressure from the Valsalva maneuver may interfere with healing and increase the risk of surgical complications such as hemorrhage or displacement of the intraocular lens. Post-op cataract patients are advised to avoid straining or lifting.

Correct Answer A. Discuss events preceding the error with the nurse.

Explanation:

The best response by the charge nurse to prevent future errors is to discuss the circumstances that led to the mistake with the nurse involved. This facilitates a non-punitive, educational approach to patient safety and allows identification of any systemic issues or knowledge gaps. Root cause analysis begins by understanding how and why the error occurred—whether it was due to calculation mistakes, distractions, or unclear protocols. This is a critical step in fostering a culture of safety, learning from errors, and implementing measures to avoid recurrence.

Why Other Options Are Wrong:

B. Complete an incident report and place it in the client's chart

Filing an incident report is appropriate, but placing it in the client’s medical chart is incorrect. Incident reports are internal risk management documents and should never be part of the medical record. Including them in the chart can introduce legal complications and does not directly contribute to preventing future errors.

C. Inform the client, family, and physician of the error

This step is ethically and legally necessary for disclosure and ensuring transparency, but it addresses response to the error rather than its prevention. While vital, it does not satisfy the question’s focus on preventing future mistakes.

D. Monitor the client for adverse effects

This is a standard part of post-error clinical management to ensure patient safety but does not contribute to preventing future errors. It is reactive, not proactive, and does not address the root causes or educational needs related to the error.

Correct Answer A. Interpret this result as normal

Explanation:

A reactive nonstress test (NST) is a reassuring sign of fetal well-being. It means that the fetal heart rate (FHR) is responding appropriately to fetal movement, demonstrating adequate oxygenation and normal autonomic function. Specifically, a reactive NST indicates there are two or more accelerations of at least 15 beats per minute above baseline, lasting at least 15 seconds within a 20-minute period. This result is considered normal and no additional immediate testing is needed unless new symptoms arise or it’s part of ongoing surveillance for a high-risk pregnancy.

Why the Other Options Are Wrong:

B. Prepare the client for a contraction stress test:

A contraction stress test (CST) is indicated when the NST is nonreactive, equivocal, or if there are concerns about uteroplacental insufficiency. Since the NST is reactive, there is no need for further immediate testing like a CST, which is more invasive and stress-inducing.

C. Anticipate an order for repeat testing:

Although some clients with high-risk pregnancies undergo serial NSTs, a single reactive NST does not in itself indicate a need for immediate repeat testing. The appropriate response here is simply to interpret the current result as normal.

D. Inquire if the patient ate prior to the test:

While maternal intake can sometimes influence fetal activity, a reactive result has already been achieved. There is no concern about insufficient fetal activity in this case, so asking about food intake is unnecessary.

Correct Answer:

A. Gestational diabetes

B. Metabolic syndrome

C. Chronic corticosteroid use

E. Obesity

Explanation:

Type II diabetes mellitus is a chronic condition marked by insulin resistance and eventual pancreatic beta-cell dysfunction. Several factors increase the risk for its development. A history of gestational diabetes indicates a predisposition to glucose intolerance, and many women with this condition go on to develop type II diabetes later in life. Metabolic syndrome—which includes central obesity, hypertension, dyslipidemia, and insulin resistance—is a strong predictor of future type II diabetes. Chronic corticosteroid use elevates blood glucose levels by antagonizing insulin action and increasing hepatic glucose production, leading to sustained hyperglycemia. Obesity, particularly central or visceral obesity, is a major modifiable risk factor that contributes significantly to insulin resistance.

Why Other Options Are Wrong:

D. Gastric bypass surgery

This is not a risk factor for type II diabetes; rather, it is often a treatment for morbid obesity and associated metabolic disorders. Bariatric procedures like gastric bypass have been shown to reduce insulin resistance and even induce remission of type II diabetes in some patients. While nutritional deficiencies may occur after surgery, the procedure itself typically improves glycemic control, not worsens it.

Correct Answer D. Patching of the unaffected eye

Explanation:

Patching the unaffected (stronger) eye is a common treatment for strabismus in young children. This forces the use of the weaker eye and helps strengthen the muscles responsible for proper alignment. Early treatment is essential to prevent amblyopia (lazy eye) and promote normal visual development. This intervention is non-invasive and often effective when implemented consistently during the critical period of visual development.

Correct Answer A. I’ve been having pain in my right calf.

Explanation:

Pain in the calf following cast placement may indicate serious complications such as deep vein thrombosis (DVT) or compartment syndrome, both of which are medical emergencies requiring immediate attention. DVT can lead to pulmonary embolism if untreated, and compartment syndrome can cause permanent tissue damage. The nurse should assess for other signs such as swelling, redness, and changes in sensation or pulses. This statement is the most alarming and warrants prompt intervention.

Why Other Options Are Wrong:

B. My right leg feels really itchy.

Itching is a common and generally benign complaint related to cast use and drying of skin. While uncomfortable, it is not immediately concerning.

C. I didn’t keep my leg elevated as the doctor asked me to.

This reflects non-compliance and may slow healing or increase swelling, but it is not an urgent safety concern.

D. When I put weight on my crutches, it makes arthritis in my wrists worse.

This describes a chronic musculoskeletal complaint unrelated to the acute condition of the casted limb and is not immediately alarming.

Correct Answer C. Visiting nurse services

Explanation:

Visiting nurse services are the most appropriate resource for a client with a new ileostomy following discharge. Clients often need continued support and education at home as they adjust to life with an ostomy. Home health nurses can assess the stoma and surrounding skin, ensure proper ostomy care, monitor for complications such as infection or leakage, and provide critical education on dietary adjustments, appliance changes, and emotional adaptation. These services bridge the transition from hospital to home and reduce the risk of readmission by ensuring that the client is managing their condition safely and effectively.

Why Other Options Are Wrong:

A. Hospice care services

This is incorrect because hospice care is designed for individuals with a terminal illness and a life expectancy of six months or less. The goal of hospice is comfort and symptom management, not curative or rehabilitative care. A client with Crohn’s disease and a new ileostomy is not terminal and typically continues treatment and self-care at home, making hospice inappropriate.

B. Rehabilitation center

This is incorrect because rehabilitation centers are primarily for patients recovering from conditions that require intensive therapy—such as post-stroke care or major orthopedic surgery. While a client with an ileostomy might need education and adjustment support, they usually do not require physical, occupational, or speech therapy in an inpatient rehab setting.

D. Long-term care facility

This is incorrect because long-term care is designed for individuals who can no longer live independently and need ongoing nursing support for chronic disabilities or severe cognitive impairments. Clients with Crohn’s disease and a new ileostomy typically retain independence and can manage their condition with appropriate home support, not long-term institutionalization.

Correct Answers:

B. Limiting alcohol intake

C. Losing weight

Explanation:

B. Limiting alcohol intake

Alcohol relaxes the upper airway muscles, worsening airway obstruction during sleep. Reducing or avoiding alcohol—especially before bedtime—can significantly decrease apnea episodes.

C. Losing weight

Weight loss reduces fat deposits around the neck and improves upper airway patency. It is one of the most effective long-term strategies for managing obstructive sleep apnea.