NCLEX Practice Questions Test Bank, Exams of Nursing

Download NCLEX Practice Questions Test Bank and more Exams Nursing in PDF only on Docsity! NCLEX Practice Questions Test Bank 300+ Questions Updated 2023-2024 and 100% Correct Answers New Latest Version When developing a teaching plan for an 18-year-old client who asks about treatments for sexually transmitted diseases, the nurse should explain that: -------- Correct Answer - -------- 3. Ceftriaxone sodium (Rocephin) may be used to treat Neisseria gonorrhoeae infections. Ceftriaxone sodium (Rocephin) may be used to treat N. gonorrhoeae infections and is commonly combined with doxycycline hyclate (Vibramycin). Both the client and her partner should be treated if gonorrhea is present. Acyclovir (Zovirax) can be used to treat herpes genitalis; however, the drug does not cure the disease. C. trachomatis infections are usually treated with antibiotics such as doxycycline or azithromycin (Zithromax). Metronidazole (Flagyl) is used to treat trichomoniasis vaginitis, not condylomata acuminata (genital warts). What is the antidote for heparin toxicty -------- Correct Answer --------- protamine sulfate What is the antidote for coumadin toxicty -------- Correct Answer --------- vitamin K A couple is visiting the clinic because they have been unable to conceive a baby after 3 years of frequent coitus. After discussing the various causes of male infertility, the nurse determines that the male partner needs further instruction when he states which of the following as a cause? -------- Correct Answer --------- 1. Seminal fluid with an alkaline pH. The client needs further instruction when he says that one cause of male infertility is decreased sperm count due to seminal fluid that has an alkaline pH. A slightly alkaline pH is necessary to protect the sperm from the acidic secretions of the vagina and is a normal finding. An alkaline pH is not associated with decreased sperm count. However, seminal fluid that is abnormal in amount, consistency, or chemical composition suggests obstruction, inflammation or infection, which can decrease sperm production. The typical number of sperm produced during ejaculation is 400 million. Frequent exposure to heat sources, such as saunas and hot tubs, can decrease sperm production, as can abnormal hormonal stimulation. Immunologic factors produced by the man against his own sperm (autoantibodies) or by the woman can cause the sperm to clump or be unable to penetrate the ovum, thus contributing to infertility. A 24-year-old woman is being assessed for a malformation of the uterus . The figure below indicates which of the following uterine malformations? -------- Correct Answer ---- ----- 2. Bicornuate uterus. Name 3 types of IV fluids -------- Correct Answer --------- Isotonic: 0.9% NS, LR, and D5w Hypotonic: 0.5% NS, 0.45% NS Hypertonic: d5 0.45% NS, D5LR, D5NS What is in a LR IV fluid -------- Correct Answer --------- NS + electrolytes When should you use NS IV fluids -------- Correct Answer --------- Use NS when you are trying to replace volume (plasma) What are the 5 stages of grief -------- Correct Answer --------- Denial, anger, bargaining, depression, and acceptance What should you remember when someone is dealing with death and grief -------- Correct Answer --------- - Encourage expression of anger - Do not take away the defense mechanism or coping mechanism the person uses in a crisis. - Customs surrounding death and dying vary among cultures. Make every attempt to understand and accommodate the family's cultural traditions when caring for a dying patient. What are nosocomial infections -------- Correct Answer --------- Infections acquired as a result of exposure to a microorganism in the hospital setting What routes of transmission are related to HIV exposure -------- Correct Answer --------- - unprotected sexual contact (most common) - exposure to blood through drug using equipment - perinatal transmission - most common for children - can occur during pregnancy, at the time of delivery, or after birth through breast feeding Nursing assessment r/t HIV -------- Correct Answer --------- -Positive result on enzyme- linked immunosorbed assay (ELISA) - CONFIRMED WITH WESTERN BLOT TEST -Polymerase chain reaction (PCR) - used with neonate - OraQuick In-Home HIV Test: positive result is only preliminary; it must be confirmed by a healthcare professional. **Ongoing assessment, interaction with the client, and client education and support are required.*** - NCLEX testing - never choose abstinence, choose educate! What should you know about HIV symptoms -------- Correct Answer --------- - 1 to 3 weeks; flu like symptoms - 8-10 years for diagnosis The nurse assesses a woman at 24 weeks gestation and is unable to find the fetal heart beat. The fetal heart beat was heard at the client's last visit 4 weeks ago. According to priority, the nurse should do the following tasks in which order? -------- Correct Answer -- ------- 4. Ask the client if the baby is or has been moving. 3. Obtain different equipment and recheck. 2. Explain that the fetal heart beat could not found at this time. 1. Call the health care provider. A primiparous client at 10 weeks gestation questions the nurse about the need for an ultra-sound. She states "I don't have health insurance and I can't afford it. I feel fine, so why should I have the test?" The nurse should incorporate which statements as the underlying reason for performing the ultrasound now? Select all that apply. -------- Correct Answer --------- 1. We must view the gross anatomy of the fetus. 2. We need to determine gestational age. A 20-year-old married client with a positive pregnancy test states, "Is it really true? I can't believe I am going to have a baby!" Which of the following responses by the nurse would be most appropriate at this time? -------- Correct Answer --------- 2. Yes it is true. How does that make you feel? A newly diagnosed pregnant client tells the nurse, "If I'm going to have all of these discomforts, I'm not sure I want to be pregnant!" The nurse interprets the client's statement as an indication of which of the following? -------- Correct Answer --------- 3. Normal ambivalence. A client, approximately 11 weeks pregnant, and her husband are seen in the antepartal clinic. The client's husband tells the nurse that he has been experiencing nausea and vomiting and fatigue along with his wife. The nurse interprets these findings as suggesting that the client's husband is experiencing which of the following? -------- Correct Answer --------- 3. Couvade syndrome. A primigravid client asks the nurse if she can continue to have a glass of wine with dinner during her pregnancy. Which of the following would be the nurse's best response? -------- Correct Answer --------- 3. You should abstain from drinking alcoholic beverages. Examination of a primigravid client having increased vaginal secretions since becoming pregnant reveals clear, highly acidic vaginal secretions. The client denies any perineal itching or burning. The nurse interprets these findings as a response related to which of the following? -------- Correct Answer --------- 4. Control of the growth of pathologic bacteria. A client has obtained Plan B (levonorgestrel 0.75 mg, 2 tablets) as emergency contraception. After unprotected intercourse , the client calls the clinic to ask questions about taking the contraceptives. The nurse realizes the client needs further explanation when she makes which of the following responses? -------- Correct Answer --------- 1. I can wait 3 to 4 days after intercourse to start taking these to prevent pregnancy. Plan B is a series of contraceptive pills similar in composition to birth control pills that have been used for the past 30 years. Plan B is the brand name for levonorgestrel 0.75 mg. Pills are most effective if taken immediately after unprotected intercourse and then again 12 hours later. Males can purchase this contraceptive as long as they are over 18 years of age. Common side effects include nausea, breast tenderness, vertigo, and stomach pain. An antenatal G2, T1, P0, Ab0, L1 client is discussing her postpartum plans for birth control with her health care provider. In analyzing the available choices, which of the following factors has the greatest impact on her birth control options? -------- Correct Answer --------- 3. Breast - or bottle-feeding plan. Birth control plans are influenced primarily by whether the mother is breast- or bottle- feeding her infant. The maternal milk supply must be well established prior to the initiation of most hormonal birth control methods. Low-dose oral contraceptives would be the exception. Use of estrogen-/progesterone-based pills and progesterone-only pills are commonly initiated from 4 to 6 weeks postpartum because the milk supply is well established by this time. Prior experiences with birth control methods have an impact on the method chosen as do to preferences of the client's partner; however, they are not the most influential factors. Desire to have another child in two years would make some methods, such as an IUD, less attractive but would still be secondary to the choice to breast-feed. After the nurse instructs a 20 year old nulligravid client on how to perform a breast self- examination, which of the following client statements indicates that the teaching has been successful? -------- Correct Answer --------- 4. If there is discharge from my nipples, I should call my health care provider. The nurse determines that the client has understood the instructions when the client says that she will notify her primary health care provider if she notices discharge or bleeding because this may be symptomatic of underlying disease. Ideally, breast self- examination should be performed about 1 week after the onset of menses because hormonal influences on breast tissue are at a low ebb at this time. The client should perform breast self-examination on the same day each month only if she has stopped menstruating (as with menopause). The client's breasts should mirror each other. If one breast is significantly larger than the other, or if there is "pitting" of breast tissue, a tumor may be present. Which of the following would be important to include in the teaching plan for the client who wants more information on ovulation and fertility management? -------- Correct Answer --------- 3. Ovulation usually occurs on day 14, plus or minus 2 days, before the onset of the next menstrual cycle. For a client with a typical menstrual cycle of 28 days, ovulation usually occurs on day 14, plus or minus 2 days, before the onset of the next menstrual cycle. Stated another way, the menstrual period begins about 2 weeks after ovulation has occurred. Ovulation does not usually occur during the menses component of the cycle when the uterine lining is being shed. In most women, the ovum survives for about 12 to 24 hours after ovulation, during which time conception is possible. The basal body temperature rises 0.5 F to 1.0 F (0.28 C to 0.56 C) when ovulation occurs. Although some women experience some pelvic discomfort during ovulation (mittelschmerz), severe or unusual pain is rare. After ovulation, the cervical mucus is thin and copious. Which of the following instructions about activities during menstruation would the nurse include when counseling an adolescent who has just begun to menstruate? -------- Correct Answer --------- 1. Take a mild analgesic if needed for menstrual pain. The nurse should instruct the client to take a mild analgesic, such as ibuprofen, if menstrual pain or "cramps" are present. The client should also eat foods rich in iron and should continue moderate exercise during menstruation, which increases abdominal tone. Avoiding cold foods will not decrease dysmenorrhea. Sexual intercourse is not prohibited during menstruation, but the male partner should wear condom to prevent expose to blood. After conducting a class for female adolescents about human reproduction, which of the following statements indicates that the school nurse's teaching has been effective? ------ -- Correct Answer --------- 1. Under ideal conditions, sperm can reach the ovum in 15 to 30 minutes, resulting in pregnancy. Under ideal conditions, sperm can reach the ovum in 15 to 30 minutes. This is an important point to make with adolescents who may be sexually active. Many people believe that the time interval is much longer and that they can wait until after intercourse to take steps to prevent conception. Without protection, pregnancy and sexually transmitted diseases can occur. When using the abstinence or calendar method, the couple should abstain from intercourse on the days of menstrual cycle when the woman is most likely to conceive. Using a 28-day cycle as an example, a couple should abstain from coitus 3 to 4 days before ovulation (days 10 through 14) and 3 to 4 days after after ovulation (days 15 through 18). Sperm from a healthy male can remain viable for 24 to 72 hours in the female reproductive tract. If the female client ovulates after coitus, there is a possibility that fertilization can occu A 20-year-old nulligravid client expresses a desire to learn more about the symptothermal method of family planning. Which of the following would the nurse include in the teaching plan? -------- Correct Answer --------- 3. Cervical mucus is carefully monitored for changes. The symptothermal method is a natural method of fertility management that depends on knowing when ovulation has occurred. Because regular menstrual cycles can vary by 1 or 2 days in either direction, the symptothermal method requires daily basal body temperature assessments plus close monitoring of cervical mucus changes. The method relies on abstinence during the period of ovulation, which occurs approximately 14 days before the beginning of the next cycle. Abstinence from coitus for 5 days after menses is unnecessary because it is unlikely that ovulation will occur during this time period (days 1 through 10). Typically, the failure rate for this method is between 10% and 20 %. Although a condom may increase the effectiveness of this method, most clients who choose natural methods are not interested in chemical or barrier types of family planning. teaching? -------- Correct Answer --------- 1. My fallopian tubes will be tied off through a small abdominal incision. Tubal ligation, a female sterilization procedure, involves ligation (tying off) or cauterization of the fallopian tubes through a small abdominal incision (laparotomy). Reversal of a tubal ligation is not easily done, and the pregnancy success rate after reversal is about 30%. After a tubal ligation, the client may engage in intercourse 2 to 3 days after the procedure. The ovaries are not generally removed during a tubal ligation. An oophorectomy involves removal of one or both ovaries. A 23-year-old nulliparous client visiting the clinic for a routine examination tells the nurse that she desires to use the basal body tempature method for family planning. The nurse should instruct the client to do which of the following? -------- Correct Answer ------ --- 2. Take her temperature at the same time every morning before getting out of bed. The basal body temperature method requires that the client take her temperature each morning before getting out of bed, preferably at the same time each day before eating or any other activity. Just before the day of ovulation, the temperature falls by 0.5℉ (0.28 C). At the time of ovulation, the temperature rises 0.4 F to 0.8 F (0.22 C to 0.44 C) because of increased progesterone secretion in response to the luteinizing hormone. The temperature remains higher for the rest of the menstrual cycle. The client should Keep a diary of about 6 months of menstrual cycles to calculate "safe" days. There is no mucus for the first 3 or 4 days after menses, and then thick, sticky mucus begins to appear. As estrogen íncreases, the mucus changes to clear, slippery, and stretchy. This condition, termed spinnbarkeit, is present during ovulation. After ovulation, the mucus decreases in amount and becomes thick and st A couple visiting the infertility clinic for the first time states that they have been trying to conceive for the past 2 years without success. After a history and physical examination of both partners, the nurse determines that an appropriate outcome for the couple would be to accomplish which of the following by the end of this visit? -------- Correct Answer -- ------- 4. Describe each of the potential causes and possible treatment modalities. By the end of the first visit, the couple should be able to identify potential causes and treatment modalities for infertility. If their evaluation shows that a treatment or procedure may hel them to conceive, the couple must then decide how to proceed, considering all of the various treatments before selecting one. Treatments can be difficult, painful, or risky. The first visit is not the appropriate time to decide on a treatment plan because theds time to adjust to the diagnosis of indtility, a crisis for most couples. Although the may be in a hurry for definitive therapy, a thorou assessment of both partners is necessary before a treatment plan can be initiated. The success rate fo achieving a pregnancy depends on both the caus and the effectiveness of the treatment, and in som s it may be only as high as 30%. The couple may desire information about alternatives to treatment, but insufficient data are avail A client is scheduled to have in vitro fertilization (IVF) as an infertility treatment. Which of the following client statements about IVF indicates that the client understands this procedure? -------- Correct Answer --------- 3. IVF involves bypassing the blocked or absent fallopian tubes. The client's understanding of the is demonstrated by the statement describing IVF as a technique that involves bypassing the blocked or absent fallopian tubes. The primary health care provider removes the ova by laparo-scope- or ultrasound-guidad transvaginal retrieval and mixes them with prepared sperm from the woman's partner or a donor. Two days later, up to four embryos are returned to the uterus to increase the likelihood of a successful pregnancy. Supplemental progesterone, not estrogen, is given to enhance the implantation process. Gamete intrafallopian transfer (GIFT) and tubal embryo transfer have a higher pregnancy rate than IVF. However, these procedures cannot be used for clients who have blocked o absent fallopian tubes because the fertilized ova are placed into the fallopian tubes, subsequently entering the uterus naturally for implantation. In IVF, fertilization of the ova by the sperm occurs outside the cl A 20-year-old primigravid client tells the nurse that her mother had a friend who died from hemorrhage about 10 years ago during a vaginal birth. Which of the following responses would be most helpful? -------- Correct Answer --------- 4. What is it that concerns you about pregnancy, labor, and childbirth? The client is verbalizing concerns about death during childbirth, thus providing the nurse with an opportunity to gather additional data. Asking the client about these concerns would be most helful to determine the client's knowledge base and to provide the nurse with the opportunity to answer any questions and clarify any misconceptions. Although the maternal mortality rate is low in the United States and Canada, maternal deaths do occur, even with modern technology. Leading causes of maternal mortality in the United States and Canada include embolism, pregnancy-induced hypertension, hemorrhage, ectopic pregnancy, and infection. Telling the client not to concern herself about what has happened in the past is not useful. It only serves to discount the client's concerns and block further therapeutic communication. Also, postponing or ignoring the client's need for a discussion about complications of pregnancy may fu A 19-year-old nulligravid client visiting the clinic for a routine examination asks the nurse about cervical mucus changes that occur during the menstrual cycle. Which of the following statements would the nurse expect to include in the client's teaching plan? ----- --- Correct Answer --------- 3. As ovulation approaches, cervical mucus is abundant and clear. As ovulation approaches, cervical mucus is abundant and clear, resembling raw egg white Ovulation generally occurs 14 days (±2 days) before the beginning of menses. During the luteal phase of the cycle, which occurs after ovulation, the cervical mucus is thick and sticky, making it difficult for sperm to pass. Changes in the cervical mucus are related to the influences of estrogen and progesterone. Cervical mucus is always present. When instructing a client about the proper use of condoms for pregnancy prevention, which of the following instructions would be included to ensure maximum effectiveness? -------- Correct Answer --------- 1. Place the condom over the erect penis before coitus. To ensure maximum effectiveness, the condom should always be placed over the erect penis before coitus. Some couples find condom use objectionable because foreplay may have to be interrupted to apply the condom. The penis, covered by the condom, should be withdrawn before the penis becomes flaccid. Otherwise sperm may escape from the condom, providing an opportunity for possible fertilization. Rather than having the condom pulled tightly over the penis before coitus, space should be left at the tip of the penis to allow the condom to hold the sperm. The client does not need a prescription for a condom with nonoxynol 9 because these are sold over the counter. A multigravid client will be using medroxyprogesterone acetate (Depo-Provera) as a family planning method. After the nurse instructs the client about this method, which of the following client statements indicates effective teaching? -------- Correct Answer ------- -- 3. One possible adverse effect is absence of a menstrual period. With medroxyprogesterone acetate, irregular menstrual cycles and amenorrhea are common adverse effects. Other adverse effects include weight gain, breakthrough bleeding, headaches, and depression. This method requires deep intramuscular injections every 3 months. The first injection should occurr within 5 days after menses. Which of the following instructions should the nurse include in the teaching plan for a 30-year-old multiparous client who will be using an intrauterine device (IUD) for family planning? -------- Correct Answer --------- 4. Severe cramping may occur when the IUD is inserted. Severe cramping and pain may occur as the evice is passed through the internal cervical os. The insertion of the device is generally done when the client is having her menses, because it is unlikely that she is pregnant at that time. Common adverse effects of IUDs are heavy menstrual bleeding and subsequent anemia, not amenorrhea. Uterine infection or ectopicpregnancy may occur. The IUD has rate of 98%), Therefore, additional protection is not necessary to prevent pregnancy. IUDs generally are less costly than other forms of contraception because they do not require additional expense. Only one insertion is necessary, in comparison to daily doses of oral contraceptives or the need for spermicides in conjunction with diaphragm use. After instructing a 40-year-old woman about osteoporosis after menopause, the nurse determines that the client needs further instruction when the client states which of the following? -------- Correct Answer --------- 3. Women of African descent are at the greatest risk for osteoporosis. Small-boned, fair-skinned women of northern European descent are at the greatest risk for osteoporosis, not women of African descent. One standard serving of yogurt is the equivalent of one glass of milk. Women who do not eat dairy products, such as women who are lactose intolerant, should consider using calcium supplements. Inadequate lifetime intake of calcium is a major risk factor for osteoporosis. Estrogen therapy, or some of the newer medications that are not estrogen based, can greatly reduce the incidence of osteoporosis. serious risk of the procedure? -------- Correct Answer --------- 2. Possible premature labor. A primigravid client at 28 weeks gestation tells the nurse that she and her husband wish to drive to visit relatives who live several hours away. Which of the following recommendations by the nurse would be best? -------- Correct Answer --------- 3. Taking the trip is okay if you stop every 1 to 2 hours and walk. The nurse is teaching a woman who is 18 weeks pregnant about seat belt safety. Identify the area that indicates that the client understands where the lap portion of the seat belt should be placed. -------- Correct Answer --------- Which of the following recommendations would be most helpful to suggest to a primigravid client at 37 weeks gestation who has leg cramps? -------- Correct Answer ---- ----- 3. Straighten the knee and flex the toes toward the chin. Which of the following recommendations would be the most appropriate preventive measure to suggest to a primigravid client at 30 weeks gestation who is experiencing occasional heartburn? -------- Correct Answer --------- 1. Eat smaller and more frequent meals during the day. A nurse eating lunch at a restaurant sees a pregnant woman showing signs of airway obstruction. When the nurse asks the woman if she needs help, the woman nods her head yes. Indicate the area where the nurse's fist should be placed to effectively administer thrusts to clear the foreign body from the airway. -------- Correct Answer ------ --- When performing Leopold's maneuvers on a primigravid client at 22 weeks gestation, the nurse performs the first maneuver to do which of the following? -------- Correct Answer --------- 2. Determine what is in the fundus. A primigravid adolescent client at approximately 15 weeks gestation who is visiting the prenatal clinic with her mother is to undergo alphafetoprotein (AFP) screening. When developing the teaching plan for this client, the nurse should include which of the following? -------- Correct Answer --------- 4. Increased levels of AFP are associated with neural tube defects Which of the following statements best identifies the rationale for why the nurse reinforces the need for continued prenatal care throughout the pregnancy with an adolescent primigravid client? -------- Correct Answer --------- 1. Pregnant adolescents are at high risk for pregnancy-induced hypertension. Which of the following would be included in the teaching plan about pregnancy-related breast changes for a primigravid client? -------- Correct Answer --------- 3. Colostrum is usually secreted by about the 16th week of gestation. A primigravid client at 32 weeks gestation is enrolled in a breast-feeding class. Which of the following statements indicate that the client understands the breast-feeding education? Select all that apply. -------- Correct Answer --------- 2. I can hold my baby several different ways during feedings. 4. If I breast-feed, my uterus will return to pre- pregnancy size more quickly. 6. I need to feed my baby when I see feeding cues and not wait until she is crying When planning a class for primigravid clients about the common discomforts of pregnancy, which of the following physiologic changes of pregnancy should the nurse include in the teaching plan? -------- Correct Answer --------- 2. Cardiac output increases by 25% to 50% during pregnancy. When teaching a primigravid client at 24 weeks gestation about the diagnostic tests to determine fetal well-being, which of the following should the nurse include? -------- Correct Answer --------- A fetal biophysical profile involves assessments of breathing movements, body movements, tone, amniotic fluid volume, and fetal heart rate reactivity. The antenatal clinic nurse is educating a gestational diabetic soon after diagnosis. Outcome evaluation for this client session will include which of the following? Select all that apply. -------- Correct Answer --------- 1. The client states the need to maintain blood glucose levels between 70 and 110 mg/dL (3.9 to 6.2 mmol/L). 2. The client describes her planned walking program while pregnant. 3. The client will strive to maintain a hemoglobin A1C of less than 6% (0.06). 5. The client will continue her prenatal vitamins, iron, and folic acid. When teaching a primigravid client how to do Kegel exercises, the nurse explains that the expected outcome of these exercises is to: -------- Correct Answer --------- 3. Strengthen the perineal muscles. During a routine clinic visit, a 25-year-old multigravid client who initiated prenatal care at 10 weeks gestation and is now in her third trimester states, "I've been having strange dreams about the baby. Last week I dreamed he was covered with hair." The nurse should tell the mother: -------- Correct Answer --------- 4. It's not uncommon to have dreams about the baby, particularly in the third trimester. A primigravid client at 36 weeks gestation tells the nurse that she has been experiencing insomnia for the past 2 weeks. Which of the following suggestions would be most helpful? -------- Correct Answer --------- 1. Practice relaxation techniques before bedtime. Which of the following client statements indicates a need for additional teaching about self care during pregnancy? -------- Correct Answer --------- 3. I should sit in a hot tub for 20 minutes to relax after working. The nurse is developing a teaching plan for a client entering the third trimester of her pregnancy. The nurse should include which of the following in the plan? Select all that apply: -------- Correct Answer --------- 3. Experimenting with mothering roles. 4. Realignment of roles and tasks. 5. Trying various caregiver roles. 6. Concern about labor and birth. A new antenatal G 6, P 4, Ab 1 client attends her first prenatal visit with her partner. The nurse is assessing this couple's psychological response to the pregnancy. which of the following requires the most immediate follow-up? -------- Correct Answer --------- 4. The father of the baby is irritated that the mother is not like she was before pregnancy. When preparing a prenatal class about endocrine changes that normally occur during pregnancy, the nurse should include information about which of the following subjects? - ------- Correct Answer --------- 4. The thyroid enlarges with an increase in basal metabolic rate. When developing a series of parent classes on fetal development, which of the following should the nurse include as being developed by the end of the third month (9 to 12 weeks)? -------- Correct Answer --------- 1. External genitalia. A primigravid client attending parenthood classes tells the nurse that there is a history of twins in her family. What should the nurse tell the client? -------- Correct Answer --------- 2. Monozygotic twins occur by chance regardless of race or heredity. During a 2-hour childbirth preparation class focusing on the labor and birth process for primigravid clients, the nurse is describing the maneuvers that the fetus goes through during the labor process when the head is the presenting part. In which order do these maneuvers occur? -------- Correct Answer --------- 1. Engagement. 2. Flexion. 3. Descent. 4. Internal rotation. A primigravid client in a preparation for parenting class asks how much blood is lost during an uncomplicated birth. The nurse should tell the woman: -------- Correct Answer --------- 1. The maximum blood loss considered within normal limits is 500 ml. Which of the following statements by a primigravid client about the amniotic fluid and sac indicates the need for further teaching? -------- Correct Answer --------- 2. Fetal nutrients are provided by the amniotic fluid. During a childbirth preparation class, a primigravid client at 36 weeks gestation tells the nurse, "My lower back has really been bothering me lately." Which of the following exercises suggested by the nurse would be most helpful? -------- Correct Answer --------- 1. Pelvic rocking. A client is experiencing pain during the first stage of labor. What should the nurse instruct the client to do to manage her pain? Select all that apply: -------- Correct Answer A multigravid client who stands for long periods while working in a factory visits the prenatal clinic at 35 weeks gestation, stating, The varicose veins in my legs have really been bothering me lately. Which of the following instructions would be helpful? -------- Correct Answer --------- 2. Take frequent rest periods with the legs elevated above the hips. A primigravid client at 8 weeks gestation tells the nurse that since having had sexual relations with a new partner 2 weeks ago, she has noticed flulike symptoms, enlarged lympth nodes, and clusters of vesicles on her vagina. The nurse refers the client to a primary health care provider because the nurse suspects which of the following sexually transmitted diseases? -------- Correct Answer --------- 4. Herpes genitalis. While caring for a 24-year-old primigravid client scheduled for emergency surgery because of a probable ectopic pregnancy, the nurse should: -------- Correct Answer ------ --- 1. Prepare to witness an informed consent for surgery. The nurse is reviewing results for clients who are having antenatal testing. The assessment data from which client warrants prompt notification of the health care provider and a further plan of care? -------- Correct Answer --------- 2. Multigravid who had a positive oxytocin challenge test. A client asks the nurse why taking folic acid is so important before and during pregnancy. The nurse should instruct the client that: -------- Correct Answer --------- 1. Folic acid is important in preventing neural tube defects in newborns and preventing anemia in mothers. A nurse is assigned to the obstetrical triage area. When beginning the assignment, the nurse is given a report about four clients waiting to be seen. Place the clients in the order in which the nurse should see them: -------- Correct Answer --------- 1. A single mother at 4 months postpartum fearful of shaking her baby when he cries. 2. An antenatal client at 16 weeks gestation who has occasional sharp pain on her left side radiating from her symphysis to her fundus. A client at a prenatal clinic has missed two appointments. The client calls the nurse to report that she has difficulty with consistent transportation. The nurse should refer the client to: -------- Correct Answer --------- 3. The clinic social worker. The nurse is working in an ambulatory obstetrics setting. What are emphasized client safety procedures for this setting? Select all that apply. -------- Correct Answer --------- 1. Handwashing or antiseptic use when entering and leaving a room. 2. Use of two client identifiers when initiating contact with a client. 4. Conduct preprocedure verification asking for client name and procedure to be performed. When selecting an NCLEX answer or determining the order of priority what should you remember or use and what is the exception? -------- Correct Answer --------- Use the ABC rule: Airway breathing, and circulation. The exception to the rule is with actual CPR, use C-A-B for CPR. Also remember safety first and acute before chronic. If the pt. is not in distress then you assess. If the pt is in distress then you should do something. If the pt has diaphorisis you should always do something. How should you address questions related to Maslow's Hierarchy of Needs -------- Correct Answer --------- Address physiological needs first, followed by safety and security needs, love and belonging needs, self esteem needs and finally self actualization needs. *When a physiological need is not addressed in the question, look for the option that addresses safety. If a question is related to the nursing process, read the question to determine the step of the nursing process. What are the steps in the nursing process and what kind of question might be related to that step. -------- Correct Answer --------- Assessment question address the gathering and verification of data. Analysis questions require the nurse to: interpret data, collect additional information, identify and communicate nursing diagnoses and determine the health team's ability to meet the pts needs. Planning questions ask about determining, prioritizing, and modifying outcomes of care. Implementation questions reflect the management and organization of care and the assignment and delegation of tasks. Be prepared for questions on client teaching. Evaluation questions focus on comparing the actual outcomes of care with the expected outcomes and on communicating and documenting findings. What are the normal ranges for H&H? What are the nursing implications -------- Correct Answer --------- Hemoglobin - Male 14-18 Female 12-16 Newborn 14-24 High altitude living increases value, slight decrease during pregnancy. Drug therapy can alter values. Hematocrit - Male 42-52 Female 37-47 Newborn 44-64 Prolonged stasis from vasoconstriction secondary to the tourniquet can alter values. Abnormalities in RBC size may alter Hct values What are the normal ranges for WBC? What can increase values? What can decrease values? How long does the postpartum period of pregnancy affect normal ranges? What range is normal during the postpartum period? -------- Correct Answer --------- Both genders 5000-10000 Newborn 9000-30000 Anesthetics, stress, exercise, and convulsions can increased values. Drug therapy can decrease values. 24-28 hr postpartum: a count as high as 25000 is normal What are the normal ranges for RBC? What can increase levels What happens to levels during pregnancy? -------- Correct Answer --------- Males: 4.7-6.1 million Female: 4.2-5.4 million Exercise and high altitudes can cause an increase levels pregnancy usually lower values drug therapy can alter values Never draw a specimen from an arm with an infusing IV. What are the normal ranges for PLATELETS? What may increase values? What may decrease values? What drugs decrease values? -------- Correct Answer --------- Both Genders: 150000- 400000 Living at high altitudes, exercising strenuously or taking oral contraceptives may increase values decreased values may be caused by hemorrhage, DIC, reduced production of platelets, infections, use of prosthetic heart valves, and drugs. Drugs that decrease platelets: acetaminophen, aspirin, chemotherapy, H2 blockers, INH, Levaquin, streptomycin, sulfonamides, thiazide diuretics. What are the normal ranges for K+? What should you keep in mind when getting a specimen? -------- Correct Answer --------- 3.5-5 is normal range for potassium Exercise of the forearm with tourniquet in place may cause an increased level. Hemolysis of specimen can result in a falsely elevated value What are the normal ranges for Na+? What should you consider when collecting a specimen? -------- Correct Answer --------- 136-145 is a normal sodium range Do Not collect from an arm with an infusing IV solution What are the normal ranges for Ca+? What type of drug can increase calcium levels? What are two tests with positive results that are associated with hypocalcemia? How do you preform the two tests? -------- Correct Answer --------- 9-10.5 for adults. slightly lower in the elder Use of thiazide diuretics can cause increased levels of calcium When should you draw a peak level? -------- Correct Answer --------- 30-60 minutes after medication administration When should you draw a trough level? -------- Correct Answer --------- 30-60 minutes before medication administration When introducing foods to infants what should you teach the new parents? -------- Correct Answer --------- Introduce one food at a time to help identify allergies. Progression of food should be "AS TOLERATED" The nursing assessment guides decisions about progression. What is civil law concerned with? -------- Correct Answer --------- Protection of the patients private rights What does criminal law deal with? -------- Correct Answer --------- Rights of individuals and society as defined by legislative laws What is nursing negligence -------- Correct Answer --------- Negligence is malpractice that is NOT intentional. It is the failure to exercise the proper degree of care required by the circumstances that a reasonably prudent person would exercise under the circumstances to avoid harming others. It is a careless act of omission or commission that results in injury to another. What is nursing malpractice? -------- Correct Answer --------- Malpractice is not always negligence. It is often referred to as professional negligence, it is a type of negligence. It is the failure to use that degree of care that a reasonable nurse would use under the same or similar circumstances. Malpractice is found when: *The nurse owed a duty to the patient *The nurse did NOT carry out the duty/breached that duty *The patient was at a high risk of injury * The nurse's failure to carry out that duty caused the patients injury Where do Standards of Care originate? -------- Correct Answer --------- Nurses are required to follow standards of care, which originate in the Nurse Practice Acts, state and federal laws, accreditation recommendations, the guidelines of professional organizations, and the written policies and procedures of the healthcare agency What are nurses responsible for related to the standards of care? -------- Correct Answer --------- Nurses are responsible for performing procedures correctly and exercising professional judgment when implementing healthcare providers prescriptions. When can the nurse NOT follow the healthcare provider's prescription and what must they do about it? -------- Correct Answer --------- Nurses MUST follow the healthcare provider's prescription unless the nurse believes that it is in error; that it violates hospital policy; or that it is harmful to the patient. The nurse makes a formal report explaining the refusal. The nurse should file an incident (occurrence) report for any situation that may result in harm to the patient. What should the nurse do related to advanced medical directives (ADs) -------- Correct Answer --------- Assess the patients knowledge of advance directives. Integrate them into the patients plan of care Provide the patient with information about advanced directives or review ADs on admission. Have the knowledge that ADs can limit life-prolonging measures when there is little or no chance of recovery What is documented in a living will? -------- Correct Answer --------- A person documents his or her wishes regarding future care in the event of terminal illness What is a durable power of attorney for healthcare? -------- Correct Answer --------- The person appoints a representative (healthcare proxy) to make healthcare decisions in a document When can restraints be used? What must the nurse do if restraints are used? -------- Correct Answer --------- Restraints can be used only: to ensure the physcial safety of the patient or other residents, when less restrictive interventions are not successful, and must have a written order of a HCP. The nurse must follow agency policy and procedure to retrain any client, Documentation of the use of restraints and of follow-up assessments must detail the attempts to use less restrictive interventions. Liability for improper or unlawful restraint lies with the nurse and the healthcare facility. 30 min pulse checks, 2 hr ROM, one on one, Related to mental Health, how long can an involuntary admission last? -------- Correct Answer --------- 72 hours What is HIPPA and what does it require? -------- Correct Answer --------- Health Insurance Portability and Accountability Act of 1996 established standards for the verbal, written and electronic exchange of private health information. HIPPA created patient rights to consent to use and disclose health information, to inspect and copy one's medical record, and to amend mistaken or incomplete information. HIPPA requires all hospitals and health agencies to have specific policies and procedures in place to ensure compliance with its standards. What is required for informed consent to be valid? -------- Correct Answer --------- the patient giving consent must be competent and of legal age. The consent is given voluntarily. The patient giving consent understands the procedure, risks/benefits, and alternative procedures. The patient has the right to have all questions answered satisfactorily. It is the duty of the HCP performing the procedure or treatment to obtain informed consent and to answer any questions the patient might have about the procedure. The RN is witnessing the signature not providing informed consent. what type of communication and leadership is it if the person says "do it my way"? ------- - Correct Answer --------- Aggressive communication/authoritarian leader What type of communication and leadership is it if the persons says "Whatever...as long as you like me." -------- Correct Answer --------- Passive communication/laissez-faire leader What type of communication and leadership is it if the person says "Lets consider the options available."? -------- Correct Answer --------- Assertive communication/democratic leader What are the five rights of delegation? -------- Correct Answer --------- 1. right task 2. right circumstance 3. right person 4. right direction/communication 5. right supervision What skills are needed for Supervision -------- Correct Answer --------- Be able to: give direction/guidance evaluate/monitor following up What is the acronym S-BAR stand for? -------- Correct Answer --------- It is a interdisciplinary communication strategy that promotes effective communication between caregivers S = situation - State the issue or problem B = background - provide history A = assessment - most recent VS and current findings R = recommendation - state what should be done What are the 3 categories of pain medications -------- Correct Answer --------- 1. non- opioids: for mild pain or in combination for moderate pain 2. Opioids: for moderate to severe pain 3. Co-analgesic or adjuvant drugs (i.e. anticonvulsants, antidepressants) for neuropathic pain Name 4 types of Nonopioid Analgesics -------- Correct Answer --------- 1. Acetaminophen: Tylenol 2. Salicylates: Aspirin, Trilisate 3. NSAIDS: ibuprofen, Indomethacin, Ketorolac, Diclofenac 4. COX-2 inhibitors: Celebrex What type of drug is Aspirin? -------- Correct Answer --------- Non opioid Analgesic Salicylates What may be some Lab findings r/t fld volume excess -------- Correct Answer --------- Everything will be decreased Decreased: BUN, Hgb/Hct, serum osmolality, urine specific gravity and electrolytes How would you treat fluid volume excess? -------- Correct Answer --------- Give Diuretics (Lasix), fluid restrictions, weigh daily, monitor K+ What can cause a fluid volume deficit -------- Correct Answer --------- Inadequate fluid intake hemorrhage vomiting or diarrhea massive edema What are some symptoms of fluid volume deficit -------- Correct Answer --------- weight loss oliguria (not enough urine) postural hypotension What lab findings may be present with a fluid volume deficit? -------- Correct Answer ----- ---- Increased BUN Increased or normal creatinine Increased H/H Increased urine specific gravity How do you treat fluid volume deficits? -------- Correct Answer --------- Strict I&O Replace with isotonic fluids monitor Bp weight daily What is most important to remember about intracellular electrolyte balance? -------- Correct Answer --------- That potassium K+ maintains osmotic pressure and if K+ is not in balance it may be life threatening. What is most important to remember about extracellular electrolyte balance? -------- Correct Answer --------- That sodium Na+ maintains most abundant osmotic pressure. When either the ECF or the ICF changes in concentration, fluid shifts from the area of lesser concentration to the area of greater concentration. What is Hyponatremia? Symptoms? and How should you treat it -------- Correct Answer --------- Hyponatremia is a sodium (Na+) level less than 135 mEq/L, it creates Neuro/confusion and muscle cramps. Check blood pressure often, restrict fluids, and be cautious with IV fluid replacement. What is Hypernatremia? What symptoms might you see? How should you treat it? ------- - Correct Answer --------- Na+ greater than 145 mEq/L May see: Pulmonary edema Neuro: seizures, thirst, fever. Do Not Use Ivs that contain sodium Restrict sodium diet Weigh daily What is Important to remember about Hypokalemia -------- Correct Answer --------- Hypokalemia is a K+ level less than 3.5 mEq/L. Affects the cardiac system: The patient may exhibit a rapid, thready pulse, flat T waves, fatigue, anorexia, and muscle cramps. Give IV potassium supplements with a max flow rate of 20 meq/hr. Encourage foods high in K+ (bananas, oranges, spinach, potatoes, milk, strawberries, apricots) What is Hyperkalemia, what might you see with the patient and how do you treat it? ----- --- Correct Answer --------- Hyperkalemia is a K+ level greater than 5 mEq/L You may see tall, tented T waves, bradycardia, muscle weakness. Treatment may include: - 10%-20% glucose with regular insulin - Kayexalate - renal dialysis may be required What is Hypocalcemia, What might the patient exhibit? How will you treat it? -------- Correct Answer --------- Hypocalcemia is a Ca2+ level of less than 8.5 meq/L It affects the muscles: You may see a + Trousseau's sign, + Chvostek's sign, diarrhea, numbness, and convulsions. Treatment may include: calcium supplements and vitamin D to absorb. If giving IV calcium, give it slowly. Teach patient to increase dietary calcium. How do you test for the Chvostek sign and what happens if there is a positive response? -------- Correct Answer --------- Elicitation: Tapping on the face at a point just anterior to the ear and just below the zygomatic bone Postitive response: Twitching of the ipsilateral facial muscles, suggestive of neuromuscular excitability caused by hypocalcemia How do you test for the Trousseau's sign and what happens if there is a positive response? -------- Correct Answer --------- Elicitation: Inflating a sphygmomanometer cuff above systolic blood pressure for several minutes Positive response: Muscular contraction including flexion of the wrist and metacarpophalangeal joints, hyperextension of the fingers, and flexion of the thumb on the palm, suggestive of neuromuscular excitability caused by hypocalcemia What is Hypercalcemia? What signs and symptoms may be present? and how do you treat it? -------- Correct Answer --------- Hypercalcemia is a calcium level above 10.5 mEq/L Calcium affects the muscles, you may see muscle weakness, constipation, n/v, dysrhythmias, and behavioral changes. Limit vitamin D intake but push fluids. Avoid calcium-based antacids. Administer calcitonin to reduce calcium Renal dialysis may be required What is the antidote for dgioxin -------- Correct Answer --------- digibind What is the drug of choice for alcohol withdraw -------- Correct Answer --------- Librium What is the drug of choice to treat pain in pts who are narcotic addicts -------- Correct Answer --------- methadone is an opioid analgesic used to detoxify and treat pain in narcotic addicts Why should be be concerned about the patient receiving potassium and digoxin -------- Correct Answer --------- potassium potentiates dig toxicity What does heparin prevent -------- Correct Answer --------- platelet aggregation What is the medication of choice for V tach -------- Correct Answer --------- lidocaine What is the medication of choice for SVT -------- Correct Answer --------- adenosine or adenocard What is the medication of choice for Asystole -------- Correct Answer --------- atropine How often is nitroglycerine administered and when should you not give it? -------- Correct Answer --------- up to 3 times (every 5 minutes) do not give when BO is less than 90/60 What does preload affect? -------- Correct Answer --------- The amount of blood that goes to the R ventricle What is afterload? -------- Correct Answer --------- the resistance that blood has to overcome when leaving the heart What type of drug will affect afterload -------- Correct Answer --------- Calcium channel blockers