Free NLEX PN Exercise (1000 Questions) 64th Edition
Free NLEX PN Exercise (1000 Questions) 64th Edition
1. A nurse is gathering data from a prenatal client with heart disease. The nurse carefully evaluates vital signs, monitors for weight gain, and checks the fluid and nutritional status to detect complications caused by:
A. Hypertrophy and increased contractility
B. The increase in circulating volume
C. Fetal cardiomegaly
D. Rh incompatibility
Answer: B. The increase in circulating volume
Rationale: Pregnancy taxes the circulating system of every woman because both the blood volume and the cardiac output increase. This is especially important to monitor in the client whose heart may not tolerate this normal increase. Hypertrophy may result in cardiac disease, but the outcome would be a decrease in contractility, not an increase. Options 3 and 4 are related to the fetus, not the prenatal client.
Test-Taking Strategy: Use the process of elimination. Identifying the client of the question will assist in eliminating options 3 and D. Knowledge of the pathophysiology behind the changes that take place in women during pregnancy will direct you to option B. Review pathophysiology in relation to cardiac disease in the maternity client if you had difficulty with this question.
Level of Cognitive Ability: Analysis
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Data Collection
Content Area: Maternity/Antepartum
Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 224.
2. During an office visit, a prenatal client with mitral stenosis states she has been under a lot of stress lately. During data collection, the client questions everything the nurse does and behaves in an anxious manner. The appropriate nursing response or action at this time would be to:
A. Tell her not to worry
B. Ignore her unfounded concerns and continue
C. Explain the purpose of the nurse’s actions and answer all questions
D. Refer the client to a counselor
Answer: C. Explain the purpose of the nurse’s actions and answer all questions
Rationale: For the prenatal cardiac client, stress should be reduced as much as possible. It is important to be certain the woman understands the purpose of any procedures so she does not worry unnecessarily. Options 1, 2, and 4 are nontherapeutic at this time. Explaining the purpose of nursing actions will assist in decreasing the stress level of the client.
Test-Taking Strategy: Use therapeutic communication techniques. Always select the option that will enhance communication and address the client’s concerns and feelings. Review these therapeutic communication techniques if you had difficulty with this question.
Level of Cognitive Ability: Application
Client Needs: Psychosocial Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Maternity/Antepartum
Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 4.
3. A perinatal client with a history of heart disease has been instructed on care at home. Which of the following statements if made by the client would indicate that the client understands her needs?
A. “There is no restriction on people who visit me.”
B. “I should avoid stressful situations.”
C. “My weight gain is not important.”
D. “I should rest on my right side.”
Answer: B. “I should avoid stressful situations.”
Rationale: Stress causes increased cardiac work load. Too much weight gain causes an increase in body requirements and stress on the heart. To avoid infections, visitors with active infections should not be allowed to visit the client. Resting should be on the left side to promote blood return.
Test-Taking Strategy: Use the process of elimination. Eliminate options 1 and 3 because of the absolute words “no” and “not.” Knowledge regarding the circulatory process during pregnancy would assist in eliminating option D. Review care to the perinatal client with a history of heart disease if you had difficulty with this question.
Level of Cognitive Ability: Comprehension
Client Needs: Health Promotion and Maintenance
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. 655.
4. A primigravida client comes to the clinic and has been diagnosed with a urinary tract infection. She has repeatedly verbalized concern regarding safety of the fetus. Which of the following client problems does the nurse identify as most important at this time?
A. Pain
B. Impaired tissue integrity
C. Urinary tract infection
D. Fear
Answer: D. Fear
Rationale: The primary concern for this client is safety of her fetus, not herself. The priority nursing diagnosis at this time is option D. Option 3 is a medical diagnosis and outside the scope of nursing practice. Pain and impaired tissue integrity are commonly seen in clients experiencing urinary tract infections, but the question includes no data to support either of the options.
Test-Taking Strategy: Use the process of elimination and focus on the information in the question. Avoid medical diagnoses (option 3) because they are outside the scope of nursing practice. There are no data in the question to support options 1 and B. Always focus on the client’s feelings first. Review the psychosocial aspects of pregnancy if you had difficulty with this question.
Level of Cognitive Ability: Comprehension
Client Needs: Psychosocial Integrity
Integrated Process: Nursing Process/Data Collection
Content Area: Maternity/Antepartum
Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed.). St. Louis: Elsevier, pp. 690-691.
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