NCLEX Exam Practice Question of the Week - 04/06/11
Question: A client gives birth to a full-term newborn with an 8/9 Apgar score. List the initial nursing care in order of their priority.
1. Place in heated crib
2. Perform physical assessment
3. Apply identification band to mother and infant
4. Instill antibiotic prophylaxis and administer vitamin K
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Answer: 1, 3, 2, 4
Rationale: The newborn’s thermoregulation mechanism is immature and an exogenous heat source is needed. Once the Apgar score has confirmed a healthy newborn and the infant is warm, the next step is to identify both mother and infant using bands with the same numbers. The newborn is now ready to be protected from contracting ophthalmia neonatorum and Chlamydia with an antibiotic, and hemorrhagic disease of the newborn with vitamin K.
Clinical Area: Childbearing and Women’s Health Nursing
Client Need: Health Promotion and Maintenance
Cognitive Level: Analysis
Nursing Process: Planning
NCLEX Exam Practice Question of the Week - 04/13/11
Elsevier NCLEX Exam Review
Question: A lecithin-sphingomyelin (L/S) ratio is ordered for a primigravida client at 35 weeks’ gestation. What is the goal of this test?
1. To determine fetal lung maturity.
2. To evaluate the level of maternal-fetal estriol production
3. To check the position of the fetal head
4. To test the intrauterine fetal-placental circulation
Question: A lecithin-sphingomyelin (L/S) ratio is ordered for a primigravida client at 35 weeks’ gestation. What is the goal of this test?
1. To determine fetal lung maturity.
2. To evaluate the level of maternal-fetal estriol production
3. To check the position of the fetal head
4. To test the intrauterine fetal-placental circulation
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Answer: 1
Rationale: An L/S ration (converts 2:1 at approximately 34 to 35 weeks’ gestation) determines the relationship of two components of the fetal lung (lecithin and sphingomyelin) known as surfactant. Adequate surfactant must be present at birth for the alveoli to maintain expansion.
Rationale: An L/S ration (converts 2:1 at approximately 34 to 35 weeks’ gestation) determines the relationship of two components of the fetal lung (lecithin and sphingomyelin) known as surfactant. Adequate surfactant must be present at birth for the alveoli to maintain expansion.
NCLEX Exam Practice Question of the Week - 04/20/11
Elsevier NCLEX Exam Review
Question: A nurse is evaluating the pin sites of a client in skeletal traction. The nurse would be least concerned with which of the following findings?
1. Inflammation
2. Serous drainage
3. Pain at a pin site
4. Purulent drainage
Question: A nurse is evaluating the pin sites of a client in skeletal traction. The nurse would be least concerned with which of the following findings?
1. Inflammation
2. Serous drainage
3. Pain at a pin site
4. Purulent drainage
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Answer: 2
Rationale: A small amount of serous oozing is expected at pin insertion sites. Signs of infection such as inflammation, purulent drainage, and pain at the pin site are not expected findings and should be reported to the physician.
Test-Taking Strategy: Use the process of elimination. Note the strategic words least concerned. Options 1 and 4 seem to indicate an infectious problem and are eliminated first. From the remaining options, note that the complaint of pain is at “a pin site.” Also, because serous drainage is an expected finding, select option 2. Review expected findings in the client with skeletal traction if you had difficulty with this question.
Rationale: A small amount of serous oozing is expected at pin insertion sites. Signs of infection such as inflammation, purulent drainage, and pain at the pin site are not expected findings and should be reported to the physician.
Test-Taking Strategy: Use the process of elimination. Note the strategic words least concerned. Options 1 and 4 seem to indicate an infectious problem and are eliminated first. From the remaining options, note that the complaint of pain is at “a pin site.” Also, because serous drainage is an expected finding, select option 2. Review expected findings in the client with skeletal traction if you had difficulty with this question.
NCLEX Exam Practice Question of the Week - 04/27/11
Elsevier NCLEX Exam Review
Question: A nurse is assessing the family dynamics of a suspected abusive family. What behavior is expected? Select all that apply.
1. Child cringes when approached
2. Child has unexplained healed injuries
3. Parents are overly affectionate toward the child
4. Child lies still while surveying the environment
5. Parents give detailed accounts of the child’s injuries
Question: A nurse is assessing the family dynamics of a suspected abusive family. What behavior is expected? Select all that apply.
1. Child cringes when approached
2. Child has unexplained healed injuries
3. Parents are overly affectionate toward the child
4. Child lies still while surveying the environment
5. Parents give detailed accounts of the child’s injuries
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Answer: 1, 2, 4
Rationale: The child cringes when approached because past experiences with adults have inflicted pain rather than comfort. Evidence of past injuries may exist but the parents do not discuss them because this would be an admission of child abuse. Abused children are always on the alert for potential future abuse. Lying motionless prevents bringing attention to them; also, in the past resisting abuse often precipitated more abuse. Abusive parents are unable to provide any emotional support. Because abusing parents try to hide the fact of abuse, explanations about injuries usually are fabricated, inconsistent, and vague.
Rationale: The child cringes when approached because past experiences with adults have inflicted pain rather than comfort. Evidence of past injuries may exist but the parents do not discuss them because this would be an admission of child abuse. Abused children are always on the alert for potential future abuse. Lying motionless prevents bringing attention to them; also, in the past resisting abuse often precipitated more abuse. Abusive parents are unable to provide any emotional support. Because abusing parents try to hide the fact of abuse, explanations about injuries usually are fabricated, inconsistent, and vague.
NCLEX Exam Practice Question of the Week - 05/04/11
Elsevier NCLEX Exam Review
Question: What is the priority nursing action for the client who is complaining of nausea in the recovery room after gastric resection?
1. Evaluate the nasogastric tube for patency.
2. Call the physician for the antiemetic order.
3. Place client in semi-Fowler’s position so that he will not aspirate.
4. Medicate the client with a narcotic analgesic.
Question: What is the priority nursing action for the client who is complaining of nausea in the recovery room after gastric resection?
1. Evaluate the nasogastric tube for patency.
2. Call the physician for the antiemetic order.
3. Place client in semi-Fowler’s position so that he will not aspirate.
4. Medicate the client with a narcotic analgesic.
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Answer: 1
Rationale: Evaluate the nasogastric tube patency; it is important to prevent nausea and vomiting. The next action would be to put the client in semi-Fowler’s position. It is very important to assess the client and take nursing measures to determine the source of the nausea and to decrease the nausea before calling the doctor.
Rationale: Evaluate the nasogastric tube patency; it is important to prevent nausea and vomiting. The next action would be to put the client in semi-Fowler’s position. It is very important to assess the client and take nursing measures to determine the source of the nausea and to decrease the nausea before calling the doctor.
NCLEX Exam Practice Question of the Week - 05/11/11
Elsevier NCLEX Exam Review
Question: The nurse is providing an educational session to new employees, and the topic is abuse of the older client. The nurse helps the employees identify that which client is most typical of a victim of abuse?
1. A 75-year-old man with moderate hypertension.
2. A 68-year-old man with newly diagnosed cataracts
3. A 90-year-old woman with advanced Parkinson’s disease
4. A 70-year-old woman with early diagnosed Lyme disease
Question: The nurse is providing an educational session to new employees, and the topic is abuse of the older client. The nurse helps the employees identify that which client is most typical of a victim of abuse?
1. A 75-year-old man with moderate hypertension.
2. A 68-year-old man with newly diagnosed cataracts
3. A 90-year-old woman with advanced Parkinson’s disease
4. A 70-year-old woman with early diagnosed Lyme disease
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Answer: 3
Rationale: Elder abuse includes physical, sexual, or psychological abuse, misuse of property, and violation of rights. The typical abuse victim is a woman of advanced age with few social contacts and at least one physical or mental impairment that limits her ability to perform activities of daily living. In addition, the client usually lives alone or with the abuser and depends on the abuser for care.
Rationale: Elder abuse includes physical, sexual, or psychological abuse, misuse of property, and violation of rights. The typical abuse victim is a woman of advanced age with few social contacts and at least one physical or mental impairment that limits her ability to perform activities of daily living. In addition, the client usually lives alone or with the abuser and depends on the abuser for care.
NCLEX Exam Practice Question of the Week - 05/18/11
Elsevier NCLEX Exam Review
Question: When talking with a client who has been receiving paroxetine (Paxil), the nurse identifies that more clarification is needed when the client states:
1. “I will be a little drowsy in the mornings.”
2. “I’m expecting to feel somewhat better but I may need other therapy.”
3. “I’ve been on the medication for 8 days now and I don’t feel any better.”
4. “I know I will probably have to take this medication for several months.”
Question: When talking with a client who has been receiving paroxetine (Paxil), the nurse identifies that more clarification is needed when the client states:
1. “I will be a little drowsy in the mornings.”
2. “I’m expecting to feel somewhat better but I may need other therapy.”
3. “I’ve been on the medication for 8 days now and I don’t feel any better.”
4. “I know I will probably have to take this medication for several months.”
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Answer: 3
Rationale: This is too short a period of time to expect a therapeutic response to an antidepressant; clients usually begin to feel a lightening of depression in approximately 14 to 20 days, with the full antidepressant effects being felt between 3 and 4 weeks. Drowsiness, fatigue, and insomnia are common side effects. Medication alone may not be effective; some form of psychotherapy often is needed. Clients usually remain on these medications for several months.
Rationale: This is too short a period of time to expect a therapeutic response to an antidepressant; clients usually begin to feel a lightening of depression in approximately 14 to 20 days, with the full antidepressant effects being felt between 3 and 4 weeks. Drowsiness, fatigue, and insomnia are common side effects. Medication alone may not be effective; some form of psychotherapy often is needed. Clients usually remain on these medications for several months.
NCLEX Exam Practice Question of the Week - 05/25/11
Question: When a client is taking theophylline (Theo-Dur), which is the highest priority for the nurse to include in the plan of care?
1. Restrict the client’s fluid intake.
2. Instruct the client to report lethargy and fatigue.
3. Assess the client for hypertension and polyuria.
4. Monitor the client for therapeutic plasma levels of the drug.
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Answer: 4
Rationale: Theophylline (Theo-Dur) has a narrow therapeutic range (10-20 mcg/mL); therefore serum levels should be monitored and dosage adjusted accordingly to achieve efficacy and to prevent toxicity. A client taking theophylline (Theo-Dur) should maintain adequate fluid intake (1). The client should be instructed to report signs of toxicity, including nausea, vomiting, tremors, nervousness, and seizures. Lethargy and fatigue (2), or hypertension and polyuria (3) are not associated signs of theophylline toxicity.
NCLEX Exam Practice Question of the Week - 06/01/11
Question: A nurse is caring for a child after spinal fusion for scoliosis treatment. The child complains of abdominal discomfort and begins to have episodes of vomiting. On further assessment, the nurse notes abdominal distention. Based on these findings, the nurse should take which action?
1. Notify the physician.
2. Administer an antiemetic.
3. Increase the intravenous fluids.
4. Place the child in a Sims’ position.
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Answer: 1
Rationale: Scoliosis is a three-dimensional spinal deformity that usually involves lateral curvature, spinal rotation resulting in rib asymmetry, and hypokyphosis of the thorax. A complication after surgical treatment of scoliosis is superior mesenteric artery syndrome. This disorder is caused by mechanical changes in the position of the child’s abdominal contents, resulting from lengthening of the child’s body. The disorder results in a syndrome of emesis and abdominal distention similar to that which occurs with intestinal obstruction or paralytic ileus. Postoperative vomiting in children with body casts or children who have undergone spinal fusion warrants attention because of the possibility of superior mesenteric artery syndrome. Options 2, 3, and 4 are incorrect.
NCLEX Exam Practice Question of the Week - 06/08/11
Elsevier NCLEX Exam Review
Question: A practitioner orders additional diagnostic studies to assess a client’s acid-base status. The laboratory value that indicates metabolic acidosis is:
1. Urine pH of 8.4
2. Gastric content pH of 6.0
3. Venous serum pH of 7.28
4. Arterial plasma pH of 7.40
Question: A practitioner orders additional diagnostic studies to assess a client’s acid-base status. The laboratory value that indicates metabolic acidosis is:
1. Urine pH of 8.4
2. Gastric content pH of 6.0
3. Venous serum pH of 7.28
4. Arterial plasma pH of 7.40
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Answer: 3
Rationale: The expected range of venous pH is 7.31 to 7.41; any condition that decreases bicarbonate anion concentration in extracellular fluid results in metabolic acidosis. Options 1 and 2 are not accurate assessments for metabolic acidosis. Option 4 is within the expected range.
Rationale: The expected range of venous pH is 7.31 to 7.41; any condition that decreases bicarbonate anion concentration in extracellular fluid results in metabolic acidosis. Options 1 and 2 are not accurate assessments for metabolic acidosis. Option 4 is within the expected range.
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