NCLEX NCLEX-PN Exam Made Easy: Step-by-Step Preparation Guide

To protect the confidentiality of the information being reported, the nurse should make the charge nurse on

the unit aware of the situation so that the information can be communicated in an appropriate way in privacy.

Coordinated Care

Choice 3 is indicative of a tension pneumothorax, which is considered a medical emergency. The respiratory system is severely compromised and venous return to the heart is affected. The mediastinal shift is to the unaffected side. Choice 1 contains symptoms of pleurisy, and Choice 2 lists symptoms of bronchitis. Neither are emergencies. The client in Choice 4 should expect difficulty breathing after exercise when asthma is an existing condition and might need immediate attention if his rescue inhaler is ineffective.Physiological Adaptation

The child has Fifth disease, a parvovirus flulike illness that is self-limiting but is contagious for two–three weeks.Safety and Infection Control

The nurse conducting discharge teaching must stress the lengthy recuperation process with emphasis on the sedative qualities of the medication used to prevent relapse. Support groups are useful for caregivers. The emphasis during recuperation is on maintaining nutrition and hygiene.Psychosocial Integrity

Most protocols require two separate clinical examinations, including induction of painful stimuli, papillary responses to light, oculovestibular testing, and apnea testing. Choices 2 and 4 have no specific test required. Choice 3 is not a current definition of death in the United States.Psychosocial Integrity

An acute hyphema occurs as a result of a blunt injury to the eye and is manifested by a half-moon appearance or a horizontal line across the globe when the client is upright (due to blood collected in the anterior chamber).Safety and Infection Control

A maturational crisis occurs when an individual arrives at a new stage of development and must develop new coping strategies. Choice 1 arises from sources external to individuals. Choice 3 occurs when some event external to a person (floods, hurricanes) disrupts his or her coping behaviors. Choice 4 is not a crisis intervention.Psychosocial Integrity

Pain on movement and weight bearing indicates pressure on the nerves or muscles caused by the dislocation. Other symptoms of dislocation include an inability to bear weight and a shortening of the affected leg. Edema is not a primary sign of displacement.Physiological Adaptation

Although clients do have the right to refuse treatment, the nurse should remain nonjudgmental and inform the client of available services. Frequently elders are not aware of existing programs.Psychosocial Integrity

The nurse acts as an advocate for the nursing profession by encouraging appropriate persons to become nurses, by being a positive role model and mentor, and by communicating the needs of nurses in the most professional manner possible, to those making the laws.Coordinated Care

Thrombocytopenia is an abnormal decrease in the number platelets, which results in bleeding tendencies. Erythrocytosis is an abnormal increase in the number of circulating red blood cells. Leukocytosis is an increase in the number of white blood cells in the blood. Polycythemia is also an excess of red blood cells and is a synonym for erythrocytosis. With chemotherapy there is a decrease in red and white blood cells, not an increase.Physiological Adaptation

Delegating is the act (or task) of assigning work to those that are capable and competent to do the work. Coaching, evaluating, and facilitating are supervisory activities that are people related.Coordinated Care

The client is describing signs and symptoms of tuberculosis. The client is potentially infectious to others and should be secluded. A respirator mask should be worn by caregivers, but it is not necessary for the nurse to don a gown and gloves. If the client is moved to other areas such as radiology, a mask should be worn by the client and a respirator mask should be worn by those working in close contact with the client.Safety and Infection Control

Hepatitis A is for individuals who travel or persons with chronic liver disease. Infants receive the hepatitis B vaccine at birth. DTaP is administered at 18 months of age. Individuals who come into contact with blood should be immunized against hepatitis B.Health Promotion and Maintenance

Drugs and drug metabolites with molecular weights higher than 300 can be excreted via the bile, stored in the gallbladder, delivered to the intestines by the bile duct, and then reabsorbed into the circulation. This process reduces the elimination of drugs and prolongs their half-life and duration of action in the body. Choice 1 is the amount of drug eliminated by the liver. Choice 2 is the sum of all types of clearance including renal, hepatic, and respiratory. Choice 4 is the amount of drug absorbed from the GI tract, then metabolized by the liver (reducing the amount of drug that makes it into circulation).Pharmacological Therapies