NGN NCLEX RN ACTUAL EXAM LATEST 2023 TEST BANK
QUESTIONS AND CORRECT DETAILED ANSWERS WITH
RATIONALES |AGRADE
QUESTION
A 35-weeks-pregnant client is undergoing a nonstress test (NST). During the 20-minute
examination, the nurse notes three fetal movements accompanied by accelerations of the fetal
heart rate, each 15 bpm, lasting
15 seconds. The nurse interprets this test to be:
• Nonreactive
• Reactive
• Positive
• Negative
Answer: B Explanation:
(A) In a nonreactive NST, the criteria for reactivity are not met. (B) A reactive NST shows at
least two accelerations of FHR with fetal movements, each 15 bpm, lasting 15 seconds or more,
over 20 minutes. (C, D) This term is used to interpret a contraction stress test (CST), or
oxytocin challenge test, not an NST.
QUESTION
A 30-year-old client has just been treated in the ER for bruises and abrasions to her face and a
broken arm from domestic violence, which has been increasing in frequency and intensity
over the last few months. The nurse assesses her as being very anxious, fearful, bewildered,
and feeling helpless as she states, “I don’t know what to do, I’m afraid to go home.” The best
response by the nurse to the client would be:
• “I wouldn’t want to go home either; call a friend who could help you.”
• “Did you do something that could have made him so angry?”
• “Let’s talk about people and resources available to you so that you don’t have to go home.”
• “I’ll call the police and they will take care of him, and you can go home and get some rest.”
• A person in crisis needs support, assistance, and direction from a caregiver rather than just
an instruction.
• A battered person may feel guilt and think that they cause the abuser’s behavior;
however, the abuser has the problem and goes through phases of violence. (C) The nurse
should provide support and guidance to the client in crisis by offering alternatives and assist
in referrals. (D) Focusing on help from law enforcement may be a very temporary solution,
because the victim may be fearful of pressing charges. This answer does not address the
crisis of going home.
QUESTION
,A 74-year-old obese man who has undergone open reduction and internal fixation of the right
hip is 8 days postoperative. He has a history of arthritis and atrial fibrillation. He admits to
right lower leg pain, described as “a cramp in my leg.” An appropriate nursing action is to:
• Assess for pain with plantiflexion
• Assess for edema and heat of the right leg
• Instruct him to rub the cramp out of his leg
• Elevate right lower extremity with pillows propped under the knee
Answer: B Explanation:
(A) Calf pain with dorsiflexion of the foot (Homans’ sign) can be a sign of a deep venous
thrombosis; however, it is not diagnostic of the condition. (B) Swelling and warmth along the
affected vein are commonly observed clinical manifestations of a deep venous thrombosis as
a result of inflammation of the vessel wall. (C) Rubbing or massaging of the affected leg is
contraindicated because of the risk of the clot breaking loose and becoming an embolus. (D)
A pillow behind the knee can be constricting and further impair blood flow.
QUESTION
A 26-year-old client is admitted to the labor, delivery, recovery, postpartum unit. The nurse
completes her assessment and determines the client is in the first stage of labor. The nurse
should instruct her:
• To hold her breath during contractions
• To be flat on her back
• Not to push with her contractions
• To push before becoming fully dilated
Answer: C Explanation:
(A) This nursing action may cause hyperventilation. (B) This nursing action could cause
inferior vena cava syndrome. (C) The client is allowed to push only after complete dilation
during the second stage of labor. The nurse needs to know the stages of labor. (D) If the
client pushes before dilation, it could cause cervical edema and/or edema to the fetal scalp; both
of these could contribute to increased risk of complications.
QUESTION
A client in active labor asks the nurse for coaching with her breathing during contractions.
The client has attended Lamaze birth preparation classes. Which of the following is the best
response by the nurse?
• “Keep breathing with your abdominal muscles as long as you can.”
• “Make sure you take a deep cleansing breath as the contractions start, focus on an object,
and breathe about 16–20 times a minute with shallow chest breaths.”
• “Find a comfortable position before you start a contraction. Once the contraction has started,
take slow
breaths using your abdominal muscles.”
, • “If a woman in labor listens to her body and takes rapid, deep breaths, she will be
able to deal with her contractions quite well.”
Answer: B Explanation:
(A) Lamaze childbirth preparation teaches the use of chest, not abdominal, breathing. (B) In
Lamaze preparation, every patterned breath is preceded by a cleansing breath; as labor
progresses, shallow, paced breathing is found to be effective. (C) It is important to assume a
comfortable position in labor, but the
Lamazeprepared laboring woman is taught to breathe with her chest, not abdominal, muscles.
(D) When deep
chest breathing patterns are used in Lamaze preparation, they are slowly paced at a rate of 6–9
breaths/min.
QUESTION
A couple is planning the conception of their first child.
The wife, whose normal menstrual cycle is 34 days in length, correctly identifies the time that
she is most likely to ovulate if she states that ovulation should occur on day:
• 14+2 days
• 16+2 days
• 20+2 days
• 22+2 days
Answer: C Explanation:
(A) Ovulation is dependent on average length of menstrual cycle, not standard 14 days. (B)
Ovulation occurs 14+2 days before next menses (34 minus 14 does not equal 16). (C)
Ovulation occurs 14+2 days before next menses (34 minus 14 equals 20). (D) Ovulation
occurs 14+2 days before next menses (34 minus 14 does not
equal 22).
QUESTION
A nurse should carefully monitor a client for the following side effect of MgSO4:
• Visual blurring
• Tachypnea
• Epigastric pain
• Respiratory depression
Answer: D Explanation:
(A, C) The nurse should provide good distractors because these symptoms indicate that PIH has
become more severe and may precede the convulsive or eclamptic phase. (B) This is the
oppositeside effect of this medication.
(D) This is a common side effect of this medication and needs to be monitored and
recorded frequently.
QUESTIONS AND CORRECT DETAILED ANSWERS WITH
RATIONALES |AGRADE
QUESTION
A 35-weeks-pregnant client is undergoing a nonstress test (NST). During the 20-minute
examination, the nurse notes three fetal movements accompanied by accelerations of the fetal
heart rate, each 15 bpm, lasting
15 seconds. The nurse interprets this test to be:
• Nonreactive
• Reactive
• Positive
• Negative
Answer: B Explanation:
(A) In a nonreactive NST, the criteria for reactivity are not met. (B) A reactive NST shows at
least two accelerations of FHR with fetal movements, each 15 bpm, lasting 15 seconds or more,
over 20 minutes. (C, D) This term is used to interpret a contraction stress test (CST), or
oxytocin challenge test, not an NST.
QUESTION
A 30-year-old client has just been treated in the ER for bruises and abrasions to her face and a
broken arm from domestic violence, which has been increasing in frequency and intensity
over the last few months. The nurse assesses her as being very anxious, fearful, bewildered,
and feeling helpless as she states, “I don’t know what to do, I’m afraid to go home.” The best
response by the nurse to the client would be:
• “I wouldn’t want to go home either; call a friend who could help you.”
• “Did you do something that could have made him so angry?”
• “Let’s talk about people and resources available to you so that you don’t have to go home.”
• “I’ll call the police and they will take care of him, and you can go home and get some rest.”
• A person in crisis needs support, assistance, and direction from a caregiver rather than just
an instruction.
• A battered person may feel guilt and think that they cause the abuser’s behavior;
however, the abuser has the problem and goes through phases of violence. (C) The nurse
should provide support and guidance to the client in crisis by offering alternatives and assist
in referrals. (D) Focusing on help from law enforcement may be a very temporary solution,
because the victim may be fearful of pressing charges. This answer does not address the
crisis of going home.
QUESTION
,A 74-year-old obese man who has undergone open reduction and internal fixation of the right
hip is 8 days postoperative. He has a history of arthritis and atrial fibrillation. He admits to
right lower leg pain, described as “a cramp in my leg.” An appropriate nursing action is to:
• Assess for pain with plantiflexion
• Assess for edema and heat of the right leg
• Instruct him to rub the cramp out of his leg
• Elevate right lower extremity with pillows propped under the knee
Answer: B Explanation:
(A) Calf pain with dorsiflexion of the foot (Homans’ sign) can be a sign of a deep venous
thrombosis; however, it is not diagnostic of the condition. (B) Swelling and warmth along the
affected vein are commonly observed clinical manifestations of a deep venous thrombosis as
a result of inflammation of the vessel wall. (C) Rubbing or massaging of the affected leg is
contraindicated because of the risk of the clot breaking loose and becoming an embolus. (D)
A pillow behind the knee can be constricting and further impair blood flow.
QUESTION
A 26-year-old client is admitted to the labor, delivery, recovery, postpartum unit. The nurse
completes her assessment and determines the client is in the first stage of labor. The nurse
should instruct her:
• To hold her breath during contractions
• To be flat on her back
• Not to push with her contractions
• To push before becoming fully dilated
Answer: C Explanation:
(A) This nursing action may cause hyperventilation. (B) This nursing action could cause
inferior vena cava syndrome. (C) The client is allowed to push only after complete dilation
during the second stage of labor. The nurse needs to know the stages of labor. (D) If the
client pushes before dilation, it could cause cervical edema and/or edema to the fetal scalp; both
of these could contribute to increased risk of complications.
QUESTION
A client in active labor asks the nurse for coaching with her breathing during contractions.
The client has attended Lamaze birth preparation classes. Which of the following is the best
response by the nurse?
• “Keep breathing with your abdominal muscles as long as you can.”
• “Make sure you take a deep cleansing breath as the contractions start, focus on an object,
and breathe about 16–20 times a minute with shallow chest breaths.”
• “Find a comfortable position before you start a contraction. Once the contraction has started,
take slow
breaths using your abdominal muscles.”
, • “If a woman in labor listens to her body and takes rapid, deep breaths, she will be
able to deal with her contractions quite well.”
Answer: B Explanation:
(A) Lamaze childbirth preparation teaches the use of chest, not abdominal, breathing. (B) In
Lamaze preparation, every patterned breath is preceded by a cleansing breath; as labor
progresses, shallow, paced breathing is found to be effective. (C) It is important to assume a
comfortable position in labor, but the
Lamazeprepared laboring woman is taught to breathe with her chest, not abdominal, muscles.
(D) When deep
chest breathing patterns are used in Lamaze preparation, they are slowly paced at a rate of 6–9
breaths/min.
QUESTION
A couple is planning the conception of their first child.
The wife, whose normal menstrual cycle is 34 days in length, correctly identifies the time that
she is most likely to ovulate if she states that ovulation should occur on day:
• 14+2 days
• 16+2 days
• 20+2 days
• 22+2 days
Answer: C Explanation:
(A) Ovulation is dependent on average length of menstrual cycle, not standard 14 days. (B)
Ovulation occurs 14+2 days before next menses (34 minus 14 does not equal 16). (C)
Ovulation occurs 14+2 days before next menses (34 minus 14 equals 20). (D) Ovulation
occurs 14+2 days before next menses (34 minus 14 does not
equal 22).
QUESTION
A nurse should carefully monitor a client for the following side effect of MgSO4:
• Visual blurring
• Tachypnea
• Epigastric pain
• Respiratory depression
Answer: D Explanation:
(A, C) The nurse should provide good distractors because these symptoms indicate that PIH has
become more severe and may precede the convulsive or eclamptic phase. (B) This is the
oppositeside effect of this medication.
(D) This is a common side effect of this medication and needs to be monitored and
recorded frequently.
