Nursing Quiz with Answer and Rationale 2018, 2019, 2020, 2021, 2022, 2023, 2024

Nursing Quiz with Answer and Rationale 2018, 2019, 2020, 2021, 2022, 2023, 2024

1. A nurse is caring for a client who had a cesarean section to deliver a nonviable fetus due to abruptio placentae. The client develops signs of disseminated intravascular coagulopathy (DIC). The spouse asks the nurse what is happening, and the nurse explains the condition. The spouse becomes upset and says to the nurse, “I lost my baby and now my wife? What am I going to do?” Which problem most appropriately addresses the situation?

A. Grieving related to loss of the baby
B. Deficient knowledge related to the disease process
C. Anxiety related to the reason the baby died
D. Hopelessness related to the loss of baby and illness of the spouse

Answer: D. Hopelessness related to the loss of baby and illness of the spouse

Rationale: A person who lacks hope experiences hopelessness and sees no way out of the situation except for death. There are no data in the question that support the diagnosis of grieving, deficient knowledge, or anxiety.

Test-Taking Strategy: Identify the client of the question, which is the spouse. Next, focus on the statement of the spouse to assist in directing you to the correct option. Options 2 and 3 can be eliminated first because they are unrelated to the spouse’s statement. From the remaining options, although the spouse is experiencing grief, note that the spouse’s statement most appropriately supports hopelessness. Review the defining characteristics for hopelessness if you had difficulty with this question.

Level of Cognitive Ability: Analysis
Client Needs: Psychosocial Integrity
Integrated Process: Nursing Process/Data Collection
Content Area: Maternity/Postpartum
Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, pp. 287, 290.

2. A nurse is caring for a client with sickle cell disease who is in labor. The nurse assures that the client receives appropriate intravenous (IV) fluid intake and oxygen consumption to primarily:

A. Stimulate the labor process
B. Avoid the necessity of a cesarean delivery
C. Prevent dehydration and hypoxemia
D. Eliminate the need for analgesic administration

Answer: C. Prevent dehydration and hypoxemia

Rationale: A variety of conditions, including dehydration, hypoxemia, infection, and exertion, can stimulate the sickling process during labor. Maintaining adequate IV fluid intake and the administration of oxygen via facemask will help to assure a safe environment for maternal/fetal health during labor. These measures will not stimulate the labor process, avoid the need for a cesarean delivery, or eliminate the need for analgesic administration.

Test-Taking Strategy: Note the relation between “appropriate IV fluid intake and oxygen consumption” in the question and “prevent dehydration and hypoxemia” in the correct option. This relation and knowledge regarding the care measures for sickle cell anemia will direct you to option C. Review care to a client with sickle cell disease who is in labor if you had difficulty with this question.

Level of Cognitive Ability: Application
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Maternity/Intrapartum
Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 226.

3. A nurse is instructing a maternity client how to keep a fetal activity diary. The nurse tells the client to:

A. Schedule the counting periods in the morning when the fetal movement is highest
B. Lie on the stomach when preparing to count the fetal movement
C. Expect the baby to move at least 35 times in 3 hours
D. Contact the physician if the baby’s movements are fewer than 10 times in 2 hours

Answer: D. Contact the physician if the baby’s movements are fewer than 10 times in 2 hours

Rationale: Most healthy fetuses move at least 10 times in 2 hours. Slowing or stopping of fetal movement may be an indication that the fetus needs some attention and evaluation. In general, women are advised to count fetal movements for 30 minutes 3 times a day. The client should lie on the left side during the procedure because it provides optimal circulation to the uterus-placenta-fetus unit. The time of day may affect fetal movement: fetal movement is lower in the morning and higher in the evening.

Test-Taking Strategy: Use the process of elimination. Read each option carefully and use knowledge regarding fetal movement to direct you to option D. If you had difficulty with this question, review client instructions regarding normal fetal activity.

Level of Cognitive Ability: Application
Client Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process/Implementation
Content Area: Maternity/Antepartum
Reference: Lowdermilk, D., & Perry, A. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, p. 997.

4. A nurse is providing health care information to a pregnant client who is human immunodeficiency virus (HIV) positive. The nurse instructs the client that it is important to avoid alcohol and cigarettes during pregnancy and to get adequate rest primarily to:

A. Avoid further stress on the maternal immune system
B. Reduce the risk of anemia during pregnancy
C. Minimize the possibility of preterm labor
D. Minimize the risk of premature rupture of membranes

Answer:  Avoid further stress on the maternal immune system

Rationale: The use of alcohol and cigarettes during the pregnancy of an HIV-infected client, as well as not getting appropriate rest, can compromise the maternal immune system and interfere with medical treatments that may be in place. Collectively, such factors may place both the mother and fetus at additional risk during the pregnancy. Option 1 identifies the primary nursing management issue for the HIV-infected client.

Test-Taking Strategy: Use the process of elimination and focus on the diagnosis of the client. Note the key words primarily in the question and immune in the correct option. Although all of the options are important, the option that specifically relates to the client with HIV is option A. Review care measures for the pregnant client with HIV if you had difficulty with this question.

Level of Cognitive Ability: Application
Client Needs: Physiological Integrity
Integrated Process: Teaching/Learning
Content Area: Maternity/Antepartum
Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed.). St. Louis: Elsevier, p. 666.

5. A pregnant client with mitral valve prolapse is receiving anticoagulant therapy during pregnancy. The nurse collects data on the client and expects that the client will indicate that which of the following medications is prescribed?

A. Oral intake of 15 mg of warfarin (Coumadin) daily
B. Intravenous infusion of heparin sodium 5000 U daily
C. Subcutaneous administration of heparin sodium 5000 U daily
D. Subcutaneous administration of terbutaline (Brethine)

Answer: C. Subcutaneous administration of heparin sodium 5000 U daily

Rationale: Pregnant women with mitral valve prolapse are frequently given anticoagulant therapy during pregnancy because they are at greater risk for thromboembolic disease during the antenatal, intrapartal, and postpartum periods. Warfarin (Coumadin) is contraindicated during pregnancy because it passes through the placental barrier, causing potential fetal malformations and hemorrhagic disorders. Heparin sodium, which does not pass through the placental barrier, is safe to use during pregnancy and would be administered by the subcutaneous route. Terbutaline is indicated for preterm labor management only.

Test-Taking Strategy: Use the process of elimination and knowledge regarding the medications that are safe during pregnancy. Eliminate options 1 and 4 first because warfarin is contraindicated and terbutaline is indicated for preterm labor management only. From the remaining options, select option 3 because of the word “subcutaneous.” Review the treatment measures for the pregnant client with mitral valve prolapse if you had difficulty with this question.

Level of Cognitive Ability: Analysis
Client Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process/Data Collection
Content Area: Maternity/Antepartum
References:
Lowdermilk, D., & Perry, A. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, p. 907.
McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed.). St. Louis: Elsevier, p. 655.

Source : NCLEX example quiz and answer

Read also:

• NCLEX Quiz and Corret Answer 9th Edition (Maternity Edition)
• Quiz NCLEX with Correct Answer (update.July 2019) 10th Edition (Maternity/Antepartum)
• Question and Answer NCLEX with Rationale 11th Edition 2019 / 2020

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