NCLEX COMPREHENSIVE EXAM QUESTIONS AND ANSWERS A+
GRADED
NCLEX COMPREHENSIVE EXAM QUESTIONS AND ANSWERS A+ GRADED
,NCLEX COMPREHENSIVE EXAM QUESTIONS AND ANSWERS A+
GRADED
repositioned. An indwelling catheter is often inserted to aid monitoring of fluid
balance and keep the bladder empty so that the uterus can contract fully, but
this is not the action that would be taken immediately.
A nurse in the postpartum unit is caring for a client who delivered a healthy
newborn 12 hours ago. The nurse checks the client's temperature and notes that
it is 100.4° F (38° C). On the basis of this finding, the nurse would: - Ans-Recheck
the temperature in 4 hours
Rationale: A temperature of 100.4° F (38° C) is common during the 24 hours after
childbirth and may be the result of dehydration or normal postpartum
leukocytosis. If the increased temperature persists for more than 24 hours or
exceeds 100.4° F (38° C), infection is a possibility, and the fever is reported. The
nurse would recheck the temperature in 4 hours. There is no reason to restrict
place the client to strict bedrest or to notify the health care provider. Although
the client would be encouraged to breastfeed her newborn, this action is
unrelated to the client's temperature.
A nurse checking the fundus of a postpartum woman notes that it is above the
expected level, at the umbilicus, and that it has shifted from the midline position
to the right. The nurse's initial action should be: - Ans-Helping the woman empty
her bladder
Rationale: In the postpartum period, the fundus should be firmly contracted and
at or near the level of the umbilicus. If the uterus is found to be higher than the
expected level or shifted from the midline position (usually to the right), the
bladder may be distended. The location of the fundus should be rechecked after
the woman has emptied her bladder. If the fundus is difficult to locate or is boggy
(soft), the nurse stimulates the uterine muscle to contract by gently massaging
the uterus. Encouraging the woman to walk is inappropriate at this time. The
nurse would document fundal position, consistency, and height and any other
interventions taken (e.g., uterine massage) after the woman has emptied her
bladder.
A nurse is preparing to care for a client who was admitted to the antepartum unit
at 34 weeks' gestation after an episode of vaginal bleeding resulting from total
placenta previa. In report, the nurse is told that the client's vital signs are stable,
that the fetal heart rate is 140 beats/min with a reassuring pattern, and that both
the client and her husband are anxious about the condition of the fetus. On
,NCLEX COMPREHENSIVE EXAM QUESTIONS AND ANSWERS A+
GRADED
reviewing the client's plan of care, which client concern does the nurse identify
as the priority at this time? - Ans-Anxiety
, NCLEX COMPREHENSIVE EXAM QUESTIONS AND ANSWERS A+
GRADED
Rationale: Anxiety is vague uneasiness or discomfort that warns of trouble and
enables an individual to approach and deal with the threat. Fluid volume loss
indicates a hypovolemic state, whereas fluid volume overload indicates a
hypervolemic state. Premature grief is a state in which an individual grieves
before an actual loss. There is no information in the question to indicate that
fluid volume loss, fluid volume overload, or premature grief are factors for
concern.
A nurse reviews the laboratory results of a hospitalized pregnant client with a
diagnosis of sepsis who is at risk for disseminated intravascular coagulopathy
(DIC). Which laboratory finding would indicate to the nurse that DIC has
developed in the client? - Ans-Positive result on d-dimer study
Rationale: DIC is a life-threatening defect in coagulation. As plasma factors are
consumed, the circulating blood becomes deficient in clotting factors and unable
to clot. Even as anticoagulation is occurring, inappropriate coagulation is also
taking place in the microcirculation, and tiny clots form in the smallest blood
vessels, blocking blood flow to the organs and causing ischemia. Laboratory
studies help establish a diagnosis. The fibrinogen value and platelet count are
usually decreased, prothrombin and activated partial thromboplastin times may
be prolonged, and levels of fibrin degradation products (the most sensitive
measurement) are increased. The d-dimer study is used to confirm the presence
of fibrin split products; a positive result is indicative of DIC.
A nurse developing a nursing care plan for a client with abruptio placentae
includes initial nursing measures to be implemented in the event of the
development of shock. After contacting the health care provider, which does the
nurse specify as the first action in the event of shock? - Ans-Placing the client in
a lateral position with the bed flat
Rationale: If the client exhibits signs of hypovolemic shock, the nurse would
contact the health care provider. The nurse would monitor fetal status closely
and take action to minimize the effects of hypovolemic shock and promote tissue
oxygenation. The client would be placed in a lateral position, with the head of the
bed flat to increase cardiac return and thus increase circulation and oxygenation
of the placenta and other vital organs. After positioning the client, the nurse
would insert IV lines in accordance with the health care provider's prescriptions
and hospital protocols so that blood and replacement fluids may be administered.
Quick preparation of the client for cesarean delivery may be necessary, but
obtaining informed consent for the procedure is not the first action. Urine output
is monitored to ensure an output of at least 30 mL/hr but, again, this is not the
GRADED
NCLEX COMPREHENSIVE EXAM QUESTIONS AND ANSWERS A+ GRADED
,NCLEX COMPREHENSIVE EXAM QUESTIONS AND ANSWERS A+
GRADED
repositioned. An indwelling catheter is often inserted to aid monitoring of fluid
balance and keep the bladder empty so that the uterus can contract fully, but
this is not the action that would be taken immediately.
A nurse in the postpartum unit is caring for a client who delivered a healthy
newborn 12 hours ago. The nurse checks the client's temperature and notes that
it is 100.4° F (38° C). On the basis of this finding, the nurse would: - Ans-Recheck
the temperature in 4 hours
Rationale: A temperature of 100.4° F (38° C) is common during the 24 hours after
childbirth and may be the result of dehydration or normal postpartum
leukocytosis. If the increased temperature persists for more than 24 hours or
exceeds 100.4° F (38° C), infection is a possibility, and the fever is reported. The
nurse would recheck the temperature in 4 hours. There is no reason to restrict
place the client to strict bedrest or to notify the health care provider. Although
the client would be encouraged to breastfeed her newborn, this action is
unrelated to the client's temperature.
A nurse checking the fundus of a postpartum woman notes that it is above the
expected level, at the umbilicus, and that it has shifted from the midline position
to the right. The nurse's initial action should be: - Ans-Helping the woman empty
her bladder
Rationale: In the postpartum period, the fundus should be firmly contracted and
at or near the level of the umbilicus. If the uterus is found to be higher than the
expected level or shifted from the midline position (usually to the right), the
bladder may be distended. The location of the fundus should be rechecked after
the woman has emptied her bladder. If the fundus is difficult to locate or is boggy
(soft), the nurse stimulates the uterine muscle to contract by gently massaging
the uterus. Encouraging the woman to walk is inappropriate at this time. The
nurse would document fundal position, consistency, and height and any other
interventions taken (e.g., uterine massage) after the woman has emptied her
bladder.
A nurse is preparing to care for a client who was admitted to the antepartum unit
at 34 weeks' gestation after an episode of vaginal bleeding resulting from total
placenta previa. In report, the nurse is told that the client's vital signs are stable,
that the fetal heart rate is 140 beats/min with a reassuring pattern, and that both
the client and her husband are anxious about the condition of the fetus. On
,NCLEX COMPREHENSIVE EXAM QUESTIONS AND ANSWERS A+
GRADED
reviewing the client's plan of care, which client concern does the nurse identify
as the priority at this time? - Ans-Anxiety
, NCLEX COMPREHENSIVE EXAM QUESTIONS AND ANSWERS A+
GRADED
Rationale: Anxiety is vague uneasiness or discomfort that warns of trouble and
enables an individual to approach and deal with the threat. Fluid volume loss
indicates a hypovolemic state, whereas fluid volume overload indicates a
hypervolemic state. Premature grief is a state in which an individual grieves
before an actual loss. There is no information in the question to indicate that
fluid volume loss, fluid volume overload, or premature grief are factors for
concern.
A nurse reviews the laboratory results of a hospitalized pregnant client with a
diagnosis of sepsis who is at risk for disseminated intravascular coagulopathy
(DIC). Which laboratory finding would indicate to the nurse that DIC has
developed in the client? - Ans-Positive result on d-dimer study
Rationale: DIC is a life-threatening defect in coagulation. As plasma factors are
consumed, the circulating blood becomes deficient in clotting factors and unable
to clot. Even as anticoagulation is occurring, inappropriate coagulation is also
taking place in the microcirculation, and tiny clots form in the smallest blood
vessels, blocking blood flow to the organs and causing ischemia. Laboratory
studies help establish a diagnosis. The fibrinogen value and platelet count are
usually decreased, prothrombin and activated partial thromboplastin times may
be prolonged, and levels of fibrin degradation products (the most sensitive
measurement) are increased. The d-dimer study is used to confirm the presence
of fibrin split products; a positive result is indicative of DIC.
A nurse developing a nursing care plan for a client with abruptio placentae
includes initial nursing measures to be implemented in the event of the
development of shock. After contacting the health care provider, which does the
nurse specify as the first action in the event of shock? - Ans-Placing the client in
a lateral position with the bed flat
Rationale: If the client exhibits signs of hypovolemic shock, the nurse would
contact the health care provider. The nurse would monitor fetal status closely
and take action to minimize the effects of hypovolemic shock and promote tissue
oxygenation. The client would be placed in a lateral position, with the head of the
bed flat to increase cardiac return and thus increase circulation and oxygenation
of the placenta and other vital organs. After positioning the client, the nurse
would insert IV lines in accordance with the health care provider's prescriptions
and hospital protocols so that blood and replacement fluids may be administered.
Quick preparation of the client for cesarean delivery may be necessary, but
obtaining informed consent for the procedure is not the first action. Urine output
is monitored to ensure an output of at least 30 mL/hr but, again, this is not the
