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NCLEX-RN Exam Questions - Part 78
1. A client has just been transferred to the floor from the labor and delivery unit following delivery of a stillborn term infant. She is very despondent. When the nurse attempts to take her vital signs, she responds in anger, stating, 'You leave me alone. You don - t care anything about me. It - s people like you who let my baby die.'The nurses best course of action is to:
A) Quietly leave her room, allowing her more private time to deal with her loss.
B) Tell her that what happened was for the best and that she is still young and can have other children.
C) Tell her how sorry you are, and let her know that her child is now a little angel in heaven.
D) Tell her how sorry you are about the loss of her baby, and acknowledge her anger as being a normal stage of grief. Assure her that you are there to help her in any way you can.
2. When a client arrives on the labor and delivery unit, she informs the nurse that she has been having contractions for the last 5 hours. Now the pain is constant and not cyclical as it was earlier. The nurse considers the possibility of uterine rupture. Which of the following symptoms would be consistent with a uterine rupture?
A) A large gush of clear fluid from the vagina
B) Systolic hypertension
C) Abdominal rigidity
D) Increased fetal movements
3. A mother called the physicians office to ask if it would help relieve her small daughters abdominal pain if she gave an enema and placed a heating pad on the abdomen. Her daughter has a fever and has vomited twice.The nurses response is based on the knowledge that:
A) The symptoms could easily have been caused by constipation, which an enema would relieve
B) Heat would help to relax the abdominal muscles and relieve her pain
C) Both heat and enemas stimulate intestinal motility and could increase the risk of perforation
D) Complaints of stomach ache are common in young children and are generally best ignored
4. An 8-year-old child is admitted to the hospital for surgery. She has had no previous hospitalizations, and both she and her family appear anxious and fearful. It will be most helpful for the nurse to:
A) Take the child to her room and calmly and matter-offactly begin to get her ready to go to the operating room
B) Take time to orient the child and her family to the hospital and the forthcoming events
C) Explain that as soon as the child goes to the operating room she will have time to answer any questions the family has
D) Tell the child and her family that there is nothing to worry about, that the operation will not take long, and she will soon be as 'good as new'
5. Following a bicycle accident, a 12-year-old client sustained a complete fracture of the left femur. He was placed in 90-90 skeletal traction with a pin in the distal end of the femur to achieve realignment and immobilization of the left femur. When providing nursing care, it is important for the nurse to remember that:
A) The nurse may lift only the weights that are applying traction in order to reposition him in bed
B) The client will need special skin care at the pin site according to hospital policy or the physician - s preference
C) The traction pull should result in an immediate increase in comfort and reduce the need for pain medication
D) The client should be discouraged from participating in self-care activities to avoid the risk of disrupting the traction
A) Quietly leave her room, allowing her more private time to deal with her loss.
B) Tell her that what happened was for the best and that she is still young and can have other children.
C) Tell her how sorry you are, and let her know that her child is now a little angel in heaven.
D) Tell her how sorry you are about the loss of her baby, and acknowledge her anger as being a normal stage of grief. Assure her that you are there to help her in any way you can.
2. When a client arrives on the labor and delivery unit, she informs the nurse that she has been having contractions for the last 5 hours. Now the pain is constant and not cyclical as it was earlier. The nurse considers the possibility of uterine rupture. Which of the following symptoms would be consistent with a uterine rupture?
A) A large gush of clear fluid from the vagina
B) Systolic hypertension
C) Abdominal rigidity
D) Increased fetal movements
3. A mother called the physicians office to ask if it would help relieve her small daughters abdominal pain if she gave an enema and placed a heating pad on the abdomen. Her daughter has a fever and has vomited twice.The nurses response is based on the knowledge that:
A) The symptoms could easily have been caused by constipation, which an enema would relieve
B) Heat would help to relax the abdominal muscles and relieve her pain
C) Both heat and enemas stimulate intestinal motility and could increase the risk of perforation
D) Complaints of stomach ache are common in young children and are generally best ignored
4. An 8-year-old child is admitted to the hospital for surgery. She has had no previous hospitalizations, and both she and her family appear anxious and fearful. It will be most helpful for the nurse to:
A) Take the child to her room and calmly and matter-offactly begin to get her ready to go to the operating room
B) Take time to orient the child and her family to the hospital and the forthcoming events
C) Explain that as soon as the child goes to the operating room she will have time to answer any questions the family has
D) Tell the child and her family that there is nothing to worry about, that the operation will not take long, and she will soon be as 'good as new'
5. Following a bicycle accident, a 12-year-old client sustained a complete fracture of the left femur. He was placed in 90-90 skeletal traction with a pin in the distal end of the femur to achieve realignment and immobilization of the left femur. When providing nursing care, it is important for the nurse to remember that:
A) The nurse may lift only the weights that are applying traction in order to reposition him in bed
B) The client will need special skin care at the pin site according to hospital policy or the physician - s preference
C) The traction pull should result in an immediate increase in comfort and reduce the need for pain medication
D) The client should be discouraged from participating in self-care activities to avoid the risk of disrupting the traction
1. Right Answer: D
Explanation: (A) Parents do need their privacy following a loss, but the nurse still has a responsibility to provide postpartum physical care. (B) This is a negative statement, which is not therapeutic. The client is not concerned about future children but is in the first stages of grief, denial, and anger. (C) This is a negative statement, which is not therapeutic. The client does not want to hear about her baby in heaven. She cannot believe that God could love or want her child more than she could. (D) Acknowledging that anger is normal and beneficial will help the client to understand the normal stages of grief. Expressing sorrow over her loss and assuring her that the support is there to take care of her physical and emotional needs will help to promote a trusting relationship.
2. Right Answer: C
Explanation: (A) This symptom would indicate a rupture of the membranes, which would be expected during labor. There would be no cause for alarm if the fluid were clear. (B)With uterine rupture and the risk of maternal shock secondary to blood loss, the most likely sign would be hypotension indicating hypovolemic shock. (C) In the event of a uterine rupture, an abdominal examination would likely reveal rigidity or tenderness. (D) The most likely finding would be a decrease in fetal movement related to fetal distress due to impaired uteroplacental blood flow. Maintaining the client on her left side would help to maximize uterine blood flow.
3. Right Answer: C
Explanation: (A) Constipation does not cause fever or vomiting but may cause anorexia. Risk of perforation outweighs the possible benefits of an enema. (B) Heat will not relieve her symptoms but will increase intestinal motility and increase the risk of perforation. (C) Heat and enemas are contraindicated where severe abdominal pain is suspected because they increase intestinal motility and the risk of perforation. (D) Complaints accompanied by physical symptoms such as pain, anorexia, and fever should never be ignored.
4. Right Answer: B
Explanation: (A) This action does nothing to prepare the child and her family for what will happen or to relieve their anxiety and fear. (B) This action provides security by preparing the child and the family for what will happen and will help to relieve fear and anxiety. (C) This action does nothing to help prepare the child for what will happen and does not give the parents permission to ask questions until later. (D) This action provides possibly false reassurance and may prevent the child and/or the family from asking pressing questions.
5. Right Answer: B
Explanation: (A) Skeletal traction, including the weights that are applying the traction, is never released by the nurse. (B) It is necessary to keep the pin site clean and free from infection. (C) When first placed in traction, the client may experience increased discomfort as a result of the traction pull fatiguing the muscle. (D) When the child in traction is allowed to participate in his care, it gives him a measure of control and helps him to cope with the situation.
Explanation: (A) Parents do need their privacy following a loss, but the nurse still has a responsibility to provide postpartum physical care. (B) This is a negative statement, which is not therapeutic. The client is not concerned about future children but is in the first stages of grief, denial, and anger. (C) This is a negative statement, which is not therapeutic. The client does not want to hear about her baby in heaven. She cannot believe that God could love or want her child more than she could. (D) Acknowledging that anger is normal and beneficial will help the client to understand the normal stages of grief. Expressing sorrow over her loss and assuring her that the support is there to take care of her physical and emotional needs will help to promote a trusting relationship.
2. Right Answer: C
Explanation: (A) This symptom would indicate a rupture of the membranes, which would be expected during labor. There would be no cause for alarm if the fluid were clear. (B)With uterine rupture and the risk of maternal shock secondary to blood loss, the most likely sign would be hypotension indicating hypovolemic shock. (C) In the event of a uterine rupture, an abdominal examination would likely reveal rigidity or tenderness. (D) The most likely finding would be a decrease in fetal movement related to fetal distress due to impaired uteroplacental blood flow. Maintaining the client on her left side would help to maximize uterine blood flow.
3. Right Answer: C
Explanation: (A) Constipation does not cause fever or vomiting but may cause anorexia. Risk of perforation outweighs the possible benefits of an enema. (B) Heat will not relieve her symptoms but will increase intestinal motility and increase the risk of perforation. (C) Heat and enemas are contraindicated where severe abdominal pain is suspected because they increase intestinal motility and the risk of perforation. (D) Complaints accompanied by physical symptoms such as pain, anorexia, and fever should never be ignored.
4. Right Answer: B
Explanation: (A) This action does nothing to prepare the child and her family for what will happen or to relieve their anxiety and fear. (B) This action provides security by preparing the child and the family for what will happen and will help to relieve fear and anxiety. (C) This action does nothing to help prepare the child for what will happen and does not give the parents permission to ask questions until later. (D) This action provides possibly false reassurance and may prevent the child and/or the family from asking pressing questions.
5. Right Answer: B
Explanation: (A) Skeletal traction, including the weights that are applying the traction, is never released by the nurse. (B) It is necessary to keep the pin site clean and free from infection. (C) When first placed in traction, the client may experience increased discomfort as a result of the traction pull fatiguing the muscle. (D) When the child in traction is allowed to participate in his care, it gives him a measure of control and helps him to cope with the situation.
80% DISCOUNT: NCLEX-RN PRACTICE EXAMS
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