Nursing Process NCLEX Questions

Correct Answer: B

Rationale: To calculate the drip rate, we first need to find the total volume of IV fluid to be administered, which is 1500 ml + 1250 ml = 2750 ml. Then, we multiply the total volume by the drop factor (2750 ml * 15 gtt/ml = 41250 gtt). Finally, we divide the total number of drops by the time in minutes (24 hours * 60 min = 1440 min) to get the drip rate: 41250 gtt / 1440 min = 28.47 gtt/min, which rounds up to 29 gtt/min. Therefore, choice B is correct. Choices A, C, and D are incorrect because they do not reflect the accurate calculation based on the given parameters.

Correct Answer: B

Rationale: The correct answer is B: Dyspnea. Dyspnea is a common sign of organ rejection after heart transplantation, indicating possible heart failure. Low white blood cell count (A) is not typically a direct sign of organ rejection. ECG changes (C) may occur but are not specific to organ rejection. Fever (D) is a non-specific symptom and can be caused by various factors. Dyspnea is a key indicator that the transplanted heart is not functioning properly and should be closely monitored.

Correct Answer: A

Rationale: Step-by-step rationale for why answer A is correct: 1. Having intercourse with just the spouse means a monogamous relationship with a trusted partner, minimizing risk of exposure to HIV. 2. It eliminates the risk of contracting HIV from multiple sexual partners. 3. This choice adheres to safer sex practices by reducing the chances of exposure to HIV. 4. This choice also promotes trust and communication within the relationship, further reducing the risk of HIV transmission. Summary: - Choice A is correct as it promotes monogamy and reduces the risk of exposure to HIV. - Choices B, C, and D do not guarantee zero risk of HIV transmission as blood donations, HIV antibodies, and condom use can still pose risks if not used or implemented correctly.

Correct Answer: B

Rationale: The correct answer is B: Thymectomy. The thymus gland is often found to be abnormal in individuals with myasthenia gravis, and removing it through thymectomy can lead to substantial remission of symptoms. This is because the thymus plays a role in the development of the immune system and may be producing antibodies that attack neuromuscular junctions in myasthenia gravis. Choice A, esophagostomy, is a surgical procedure to create an opening in the esophagus for feeding and has no direct impact on myasthenia gravis. Choice C, myomectomy, is the removal of uterine fibroids and is unrelated to myasthenia gravis. Choice D, spleenectomy, is the removal of the spleen and is not a treatment for myasthenia gravis as the spleen is not implicated in the disease process.

Correct Answer: C

Rationale: Rationale for Answer C: Antibodies are produced by the B-cells. B-cells are a type of lymphocyte that differentiate into plasma cells, which are responsible for producing antibodies in response to antigens. This process is a key component of the humoral immune response. Therefore, the statement that antibodies are produced by the B-cells is true. Summary of Incorrect Choices: A: Antibody-mediated defense occurs through the B-cell system, not the T-cell system. T-cells are involved in cell-mediated immunity. B: Cellular immunity is mediated by T-cells, not antibodies produced by B-cells. D: Lymphocytes increasing with an allergic response is not directly related to the production of antibodies by B-cells. Allergic responses involve a different mechanism.