NCLEX RN

Correct Answer C. Loss of appetite and restlessness

Explanation

Stimulants like methylphenidate commonly cause decreased appetite, weight loss, abdominal pain, headache, and CNS stimulation (restlessness/irritability, insomnia). Cardiovascular effects can include increased heart rate and increased blood pressure, so routine monitoring of BP, pulse, height, and weight is essential. Practical counseling: give the dose in the morning (and at lunch if twice daily), offer high-calorie meals when appetite is best (breakfast/evening), avoid late-day dosing to reduce insomnia, and report chest pain, syncope, or severe mood changes.

Why the other options are wrong

A. Decreased blood pressure and growth delays

Growth deceleration can occur with long-term stimulant use, but stimulants typically raise rather than lower blood pressure. Pairing “decreased BP” with growth delay is inaccurate for methylphenidate’s usual profile.

B. Heart palpitations and weight gain

Palpitations can occur, but stimulants generally suppress appetite and may lead to weight loss, not weight gain. This combination misrepresents the expected nutritional effect.

D. Trouble sleeping and a dry cough

Insomnia is common, but a dry cough is not a typical adverse effect of methylphenidate (think ACE inhibitors for cough). Listing cough alongside insomnia makes this pair less accurate than the classic appetite suppression/restlessness profile.

Correct Answer A. Strain his urine

Explanation:

In prostate cancer treatment with iridium seed implants (brachytherapy), there is a small risk that the radioactive seeds may be passed in the urine. Therefore, clients are instructed to strain urine to detect and safely handle any dislodged seeds. This is a key part of discharge teaching to protect both the patient and others from radiation exposure.

Why the other options are incorrect:

B. Increase his fluid intake

While maintaining hydration is generally good, it is not the priority teaching specific to iridium seed implants.

C. Report urinary frequency

Urinary frequency is a common side effect of prostate cancer treatments but does not require immediate reporting unless severe.

D. Avoid prolonged sitting

This is not specific to brachytherapy teaching. Prolonged sitting does not directly affect the safety or effectiveness of the implants.

Correct Answer B. A client admitted with a suspected subdural hematoma

Explanation:

A subdural hematoma can cause rapid deterioration due to bleeding into the cranial cavity, leading to increased intracranial pressure, herniation, or death if untreated. This client is the highest priority because their condition is unstable and life-threatening, requiring immediate assessment and potential intervention.

Why the other options are incorrect:

A. A client with a supratentorial tumor awaiting surgery

While brain tumors are serious, this client is stable while awaiting surgery and does not present an immediate emergency compared to acute bleeding.

C. A client recently diagnosed with akinetic seizures

This client requires monitoring and management but is not in acute danger unless a seizure is occurring at the moment.

D. A client transferring to the neuro rehabilitation unit

This client is stable enough for rehabilitation, meaning they are the lowest priority for immediate assessment.

Correct Answer B. Asking if the client has allergies to shellfish

Explanation:

The contrast dye used in an intravenous pyelogram (IVP) is iodine-based. Clients with shellfish or iodine allergies are at risk for severe allergic reactions, including anaphylaxis. Assessing for allergies is the highest priority before the procedure because it directly impacts client safety and determines whether the test can proceed safely.

Why the other options are incorrect:

A. Providing the client with a favorite meal for dinner

This is incorrect because clients are usually placed on dietary restrictions (such as NPO after midnight) before the procedure. A special meal has no priority over safety screening for allergies.

C. Encouraging fluids the evening before the test

This may help with hydration, but clients are often instructed to restrict fluids or remain NPO before the procedure. It is not the priority compared to assessing allergies to contrast dye.

D. Telling the client what to expect during the test

Providing information and reducing anxiety are important, but ensuring the client will not have a life-threatening allergic reaction is the top priority.

The Correct Answer is A. Vitamin B12

Elevated homocysteine levels are commonly associated with deficiencies in Vitamin B12, Vitamin B6, or folate (Vitamin B9). These vitamins are necessary cofactors in the metabolism of homocysteine to methionine or cysteine. Without adequate Vitamin B12, homocysteine accumulates in the blood, increasing the risk of cardiovascular disease, stroke, and clotting disorders.

Why the other options are incorrect:

B. Vitamin C

Vitamin C deficiency leads to scurvy, characterized by bleeding gums, poor wound healing, and bruising. It does not elevate homocysteine levels.

C. Vitamin A

Vitamin A is important for vision, epithelial integrity, and immune function. Deficiency does not influence homocysteine metabolism.

D. Vitamin E

Vitamin E is an antioxidant that protects cell membranes. Its deficiency causes neurologic and hematologic problems but does not affect homocysteine levels.

Correct Answers:

A. Task

B. Circumstance

D. Supervision

E. Skill

Explanation of Correct Answers:

A. Task

Venipuncture is not an appropriate task for delegation to an unlicensed assistant. It requires technical skill and nursing judgment, so the nurse breached the principle of selecting an appropriate task.

B. Circumstance

The UA had only been off orientation for five days and was not adequately prepared for a complex, invasive procedure like venipuncture. The situation was not appropriate for delegation.

D. Supervision

The nurse did not provide adequate supervision for a high-risk skill delegated to an inexperienced UA. Effective delegation requires ongoing oversight to ensure client safety.

E. Skill

The UA lacked the necessary competence and skill level to perform venipuncture safely, resulting in client harm (hematoma). Delegating outside their skill set breaches this principle.

Why the other option is incorrect:

C. Communication

There is no evidence of poor communication. The UA appropriately reported the complication to the nurse, which indicates effective communication was maintained in this situation.

Correct Answer D. Parent states that the umbilical cord stump of a 5-day-old client is moist at the base and slightly red.

Explanation:

Redness and moisture at the umbilical cord stump may indicate infection (omphalitis), which can quickly progress to systemic infection in newborns due to their immature immune system. This requires immediate assessment and intervention, making it the most urgent message to return. Prompt treatment prevents complications such as sepsis.

Why the other options are incorrect:

A. Parent states the extremities of a 2-day-old client extend and return to the previous position when the crib is bumped.

This describes the Moro reflex, which is normal in newborns up to 4 months of age. No urgent intervention is required.

B. Parent states that the circumcision site of a 3-day-old client is covered with yellowish exudate.

A yellowish crust on a healing circumcision site is a normal finding, not a sign of infection. Parents should be reassured rather than alarmed.

C. Parent states that a 4-day-old client who is formula fed has had one stool per day for the past 2 days.

This is within normal limits for a formula-fed infant, as stool frequency can vary. It does not require urgent follow-up.

Correct Answer B. Urinary output 20 mL in the past hour

Explanation:

After abdominal aortic aneurysm repair, urinary output is a critical indicator of renal perfusion. Normal output should be at least 30 mL/hour. An output of only 20 mL in one hour suggests decreased renal blood flow, hypovolemia, or possible renal artery occlusion, all of which require immediate evaluation. Prompt intervention is needed to prevent acute kidney injury.

Why the other options are incorrect:

A. Pedal pulses regular

This is a positive finding, showing adequate peripheral circulation. It does not indicate a complication.

C. Blood pressure 108/50

This is on the lower side but can be acceptable postoperatively. It is not as immediately concerning as reduced urine output.

D. Oxygen saturation 97%

This is within normal limits and does not indicate a problem.

Correct Answer C. Asking the UAP to assess and evaluate the client response to IV pain medication

Explanation of Correct Answer:

C. Asking the UAP to assess and evaluate the client response to IV pain medication

Assessment and evaluation require clinical judgment and critical thinking, which fall within the RN’s scope of practice, not the UAP’s. A UAP may report observations such as a client stating, “I’m still in pain,” but cannot independently assess or evaluate a client’s response to IV medication.

Why the other options are incorrect:

A. Instructing the LPN to reinforce teaching of the RN's assigned clients prior to discharge

This is appropriate delegation. The RN provides the initial teaching, and the LPN can reinforce previously taught material as part of their scope of practice.

B. Assigning UAPs to complete vital signs and document and report changes to the RN

This is an appropriate task for a UAP. They can obtain and record vital signs, but the RN is responsible for interpreting and acting upon abnormal findings.

D. Instructing the LPN to remove a dressing from a postoperative client's abdominal wound

This is within the LPN’s scope of practice. LPNs can provide wound care, including dressing changes, as long as the RN assesses the client’s overall condition and directs the care plan.