NGN NCLEX RN ACTUAL EXAM LATEST 2023 TEST BANK
QUESTIONS AND CORRECT DETAILED ANSWERS WITH
RATIONALES |AGRADE
A 79-year-old client with Alzheimer’s disease is exhibiting significant memory impairment,
cognitive impairment, extremely impaired judgment in social situations, and agitation when
placed in a new situation or around unfamiliar people. The nurse should include the following
strategy in the client’s care:
• Maintain routines and usual structure and adhere to schedules.
• Encourage the client to attend all structured activities on the unit, whether she wants to or
not.
• Ask the client to go to an activity once. If she gives no response right away, change
the question around, asking the same thing.
• Give the client two or three choices to decide what she wants to do.
Answer: A Explanation:
(A) Alzheimer’s clients cope poorly with changes in routine because of memory deficits.
Schedule changes cause confusion and frustration, whereas adhering to schedules is helpful
and supports orientation. (B) Insisting that the client go to all unit activities may antagonize
her and increase her agitation because of cognitive impairments. It may be better to allow the
client time for calming down or distraction rather than to insist that she attend every activity.
(C) When repeating a question, allow time first for a response;then use the same words the
second time to avoid further confusion. (D) The nurse should avoid giving several choices at
once. Cognitively impaired clients will become more frustrated with making decisions.
QUESTION
A client has been admitted to the labor and delivery unit in active labor. After assessing her,
the RN notes that the client’s fetus position is left occipital posterior. Which of the following
statements best describes what this means to the labor process:
• Decreases the overall time of the labor process
• Prolongs the client’s first stage of labor
• Decreases the time of the client’s first stage of labor
• Prolongs the client’s third stage of labor
Answer: B Explanation:
(A) Posterior position causes a larger diameter of the fetal head to enter the pelvis than an
anterior position. Pressure on the sacral nerves is increased, and it takes the fetus a longer
time to enter the pelvic inlet. (B) This position will prolong the first stage of labor. When the
larger diameter of the fetal head enters the pelvis first, it will have a more difficult time
accommodating to the pelvis; therefore, it will take a longer time for the fetus to move
through the pelvis. (C) It will increase the time of labor because the larger diameter of the
fetal head will have a more difficult time accommodating to the pelvic inlet and thus will
,move through the pelvis slower. (D)In the third stage of labor the placenta is delivered;
therefore, the infant has been delivered.
QUESTION
On a mother’s 2nd postpartum day after having a vaginal delivery, the RN is preparing to
assess her perineum and anus as part of her daily assessment. The best position for the client
to be placed in for this assessment is:
• Sims’
• Fowler’s
• Prone
• Any position that the RN choosesAnswer: A
Explanation:
(A) The Sims’ position is the best position for assessment of the perineum and anus. The top
leg is placed over the bottom leg, and the RN raises the upper buttocks to fully expose the
perineum and anus. (B) Fowler’s position is a sitting position, and the perineum and anus
would not be exposed. (C) The prone position would have the mother on her back,
and her perineum and anus would not be exposed. (D) The position of choice should always be
the Sims’.
QUESTION
A laboring client presents with a prolapsed cord. The nurse should immediately place the client
in what position?
• Reverse Trendelenburg
• Fowler’s
• Trendelenburg
• Sims’
Answer: C Explanation:
(A) Reverse Trendelenburg position increases pressure on the perineum. This position
will not relieve cord pressure. (B) Fowler’s position increases perineal pressure. Cord
pressure would not be relieved. (C) Trendelenburg position will decrease perineal
pressure. Cord compression will be decreased and increase infetal blood flow occurs. (D)
Sims’ position does not relieve pressure on cord or perineum.
QUESTION
After an infant is delivered by cesarean delivery and placed on the warmer, the RN dries and
assesses the infant. At 1 and 5 minutes after birth, the RN does the Apgar scoring of the
infant. The RN knows that because this infant was delivered by cesarean section, he is at
increased risk for having which one of the following:
• Cold stress
• Cyanosis
• Respiratory distress syndrome
, • Seizures
Answer: C Explanation:
(A) The infant is placed on the warmer and dried after birth. Cold stress occurs when the infant
is not dried andkept warm. (B) The fact that this infant was born by cesarean delivery does not
place him at a greater risk for cyanosis than an infant delivered vaginally.
Cyanosis occurs when infants cannot oxygenate their blood after the umbilical cord is
severed. (C) Infants bornby cesarean delivery are at a higher risk for developing respiratory
distress syndrome because these infants do not pass through the pelvis, where the chest is
compressed and fluid is able to escape from the lungs. (D) Cesarean-delivered infants are not
at greater risk for seizures than infants delivered vaginally.
QUESTION
A client who is 7 months pregnant is diagnosed with pyelonephritis. The nurse
anticipates the physicianordering:
• Oxytocin
• Magnesium sulfate (MgSO4)
• Ampicillin
• Tetracycline
Answer: C Explanation:
(A) Oxytocin is prescribed to stimulate uterine contractions. (B) MgSO4is a central nervous
system depressant prescribed to prevent and control convulsions related to preeclampsi
A. (C) Ampicillin
is a penicillin derivative with no known teratogenic effects. This is the safest antibiotic during
pregnancy. (D)
Tetracycline
stains teeth yellow and is not as safe as ampicillin during pregnancy.
QUESTION
What is the appropriate nursing action for a child with increased intracranial pressure?
• Head of bed elevated 45 degrees with child’s head maintained in a neutral position
• Child lying flat
• Head turned to side
• Frequent visitation for stimulation
Answer: A Explanation:
(A) Elevation of head of bed and neutral head position promote drainage of cerebrospinal
fluid. (B) Flat position increases intracranial pressure and impedes cerebrospinal fluid
drainage. (C) Head turned to either side impedes cerebrospinal fluid drainage. (D) Child
should be in a calm, quiet environment with minimal stimulation.
QUESTION
QUESTIONS AND CORRECT DETAILED ANSWERS WITH
RATIONALES |AGRADE
A 79-year-old client with Alzheimer’s disease is exhibiting significant memory impairment,
cognitive impairment, extremely impaired judgment in social situations, and agitation when
placed in a new situation or around unfamiliar people. The nurse should include the following
strategy in the client’s care:
• Maintain routines and usual structure and adhere to schedules.
• Encourage the client to attend all structured activities on the unit, whether she wants to or
not.
• Ask the client to go to an activity once. If she gives no response right away, change
the question around, asking the same thing.
• Give the client two or three choices to decide what she wants to do.
Answer: A Explanation:
(A) Alzheimer’s clients cope poorly with changes in routine because of memory deficits.
Schedule changes cause confusion and frustration, whereas adhering to schedules is helpful
and supports orientation. (B) Insisting that the client go to all unit activities may antagonize
her and increase her agitation because of cognitive impairments. It may be better to allow the
client time for calming down or distraction rather than to insist that she attend every activity.
(C) When repeating a question, allow time first for a response;then use the same words the
second time to avoid further confusion. (D) The nurse should avoid giving several choices at
once. Cognitively impaired clients will become more frustrated with making decisions.
QUESTION
A client has been admitted to the labor and delivery unit in active labor. After assessing her,
the RN notes that the client’s fetus position is left occipital posterior. Which of the following
statements best describes what this means to the labor process:
• Decreases the overall time of the labor process
• Prolongs the client’s first stage of labor
• Decreases the time of the client’s first stage of labor
• Prolongs the client’s third stage of labor
Answer: B Explanation:
(A) Posterior position causes a larger diameter of the fetal head to enter the pelvis than an
anterior position. Pressure on the sacral nerves is increased, and it takes the fetus a longer
time to enter the pelvic inlet. (B) This position will prolong the first stage of labor. When the
larger diameter of the fetal head enters the pelvis first, it will have a more difficult time
accommodating to the pelvis; therefore, it will take a longer time for the fetus to move
through the pelvis. (C) It will increase the time of labor because the larger diameter of the
fetal head will have a more difficult time accommodating to the pelvic inlet and thus will
,move through the pelvis slower. (D)In the third stage of labor the placenta is delivered;
therefore, the infant has been delivered.
QUESTION
On a mother’s 2nd postpartum day after having a vaginal delivery, the RN is preparing to
assess her perineum and anus as part of her daily assessment. The best position for the client
to be placed in for this assessment is:
• Sims’
• Fowler’s
• Prone
• Any position that the RN choosesAnswer: A
Explanation:
(A) The Sims’ position is the best position for assessment of the perineum and anus. The top
leg is placed over the bottom leg, and the RN raises the upper buttocks to fully expose the
perineum and anus. (B) Fowler’s position is a sitting position, and the perineum and anus
would not be exposed. (C) The prone position would have the mother on her back,
and her perineum and anus would not be exposed. (D) The position of choice should always be
the Sims’.
QUESTION
A laboring client presents with a prolapsed cord. The nurse should immediately place the client
in what position?
• Reverse Trendelenburg
• Fowler’s
• Trendelenburg
• Sims’
Answer: C Explanation:
(A) Reverse Trendelenburg position increases pressure on the perineum. This position
will not relieve cord pressure. (B) Fowler’s position increases perineal pressure. Cord
pressure would not be relieved. (C) Trendelenburg position will decrease perineal
pressure. Cord compression will be decreased and increase infetal blood flow occurs. (D)
Sims’ position does not relieve pressure on cord or perineum.
QUESTION
After an infant is delivered by cesarean delivery and placed on the warmer, the RN dries and
assesses the infant. At 1 and 5 minutes after birth, the RN does the Apgar scoring of the
infant. The RN knows that because this infant was delivered by cesarean section, he is at
increased risk for having which one of the following:
• Cold stress
• Cyanosis
• Respiratory distress syndrome
, • Seizures
Answer: C Explanation:
(A) The infant is placed on the warmer and dried after birth. Cold stress occurs when the infant
is not dried andkept warm. (B) The fact that this infant was born by cesarean delivery does not
place him at a greater risk for cyanosis than an infant delivered vaginally.
Cyanosis occurs when infants cannot oxygenate their blood after the umbilical cord is
severed. (C) Infants bornby cesarean delivery are at a higher risk for developing respiratory
distress syndrome because these infants do not pass through the pelvis, where the chest is
compressed and fluid is able to escape from the lungs. (D) Cesarean-delivered infants are not
at greater risk for seizures than infants delivered vaginally.
QUESTION
A client who is 7 months pregnant is diagnosed with pyelonephritis. The nurse
anticipates the physicianordering:
• Oxytocin
• Magnesium sulfate (MgSO4)
• Ampicillin
• Tetracycline
Answer: C Explanation:
(A) Oxytocin is prescribed to stimulate uterine contractions. (B) MgSO4is a central nervous
system depressant prescribed to prevent and control convulsions related to preeclampsi
A. (C) Ampicillin
is a penicillin derivative with no known teratogenic effects. This is the safest antibiotic during
pregnancy. (D)
Tetracycline
stains teeth yellow and is not as safe as ampicillin during pregnancy.
QUESTION
What is the appropriate nursing action for a child with increased intracranial pressure?
• Head of bed elevated 45 degrees with child’s head maintained in a neutral position
• Child lying flat
• Head turned to side
• Frequent visitation for stimulation
Answer: A Explanation:
(A) Elevation of head of bed and neutral head position promote drainage of cerebrospinal
fluid. (B) Flat position increases intracranial pressure and impedes cerebrospinal fluid
drainage. (C) Head turned to either side impedes cerebrospinal fluid drainage. (D) Child
should be in a calm, quiet environment with minimal stimulation.
QUESTION
