NCLEX NCLEX-PN - National Council Licensure Examination(NCLEX-PN)

Pneumococcal vaccine should be administered as a supplemental vaccine. Hepatitis A vaccine is for travelers

and individuals with chronic liver disease. The Lyme disease vaccine is for people between the ages of 15 and

70 who are at risk for Lyme disease (transmitted by ticks primarily). The typhoid vaccine is for workers in

microbiology laboratories who frequently work with Salmonella typhi.Health Promotion and Maintenance

Choice 2 is part of the Crisis Intervention Model. Counseling by a nurse specialist at the time of a stressful

event (rape) can strengthen the client’s coping. A nurse specialist in rape crisis intervention is educationally

prepared in counseling and crisis intervention specific to rape victims.Coordinated Care

Using a direct approach is best when asking about suspected abuse. Clients are reluctant to report abuse

because of shame and fear of reprisal.Psychosocial Integrity

All the choices are elements of the ANA Code of Ethics for Nurses.Coordinated Care

A situational crisis is an unexpected, unplanned event, such as the death of a spouse. Option 1 is a normal

maturational crisis; Choices 2 and 3 are not recognized crisis states.Coordinated Care

A combined low PO2 and lowSaO2 indicates hypoxia. The pH, PCO2, and HCO3 are normal. ABGs are not

necessarily altered in TB or pleural effusion. Depending on the degree of the pneumonia, the PO2 and PCO2

might be low because hypoxia stimulates hyperventilation.Physiological Adaptation

The purpose of the PSDA is to promote decision-making prior to need. Choices 1, 3 and 4 are incorrect. The

focus of the PSDA is individual health care decision-making. A federal standard for advance directives does not

exist. Each state has jurisdiction regarding these policies and protocols.Coordinated Care

Confidentiality is the maintenance of privacy of information. The question does not suggest that confidentiality

has been breached. The client is likely to demand the other rights and may exercise them in choosing to leave the

hospital early.Coordinated Care

The nurse needs to recognize her own beliefs and biases and learn about the client’s cultural beliefs.

Psychosocial Integrity

Tattooing puts a client at risk for blood-borne hepatitis B or C if strict sterile procedures are not followed.

Tuberculosis is an airborne pathogen, while herpes and syphilis are spread directly (such as through sexual

contact).Safety and Infection Control

Chemotherapy causes damage to cells, and uric acid is a cell metabolite.Physiological Adaptation

A realistic short-term goal is for the client to verbalize feelings about the event. A brief treatment program is

not designed to identify or resolve problems. The focus is on managing acute symptoms. If in-depth psychological

problems are identified, the nurse might make referrals for treatment.Psychosocial Integrity

Fifth’s disease, erythema infectiosum, is uncommon in adults. All the other statements are correct.Safety and

Infection Control

A client with an infection needs both antibiotics as soon a possible. However, the pH of ampicillin is 8–10,

and the pH of gentamicin is 3–5.5 (making them incompatible when given together). Flushing well between

drugs is necessary. Choice 3 is incorrect because the PN determines the correct steps and consults with the

pharmacist and the physician as necessary. Choice 4 is incorrect because delaying the second medication by

several hours slows the treatment of the client’s infection.Pharmacological Therapies

Attaching a restraint to a movable part of the bed can cause client injury if that part of the bed is moved

before releasing restraints.Safety and Infection Control