NCLEX Practical Nursing with Answers 101th Edition

NCLEX Practical Nursing with Answers 101th Edition

1. A nurse is caring for a woman in labor. The nurse is monitoring the baseline fetal heart rate (FHR) and would document that the FHR is normal if which of the following were noted?

A. 105 beats per minute (BPM)
B. 150 BPM
C. 170 BPM
D. 180 BPM

Answer: B. 150 BPM

Rationale: The normal baseline FHR has a lower limit of 120 BPM and an upper limit of 150 to 160 BPM. Baseline bradycardia is a FHR less than 120 BPM. Mild bradycardia is 110 to 119 BPM. Severe bradycardia is less than 100 BPM. Baseline tachycardia is a FHR above 160 BPM. Mild tachycardia is 160 to 180 BPM, and severe tachycardia is greater than 180 BPM.

Test-Taking Strategy: Use the process of elimination. Eliminate options 3 and 4 because they are excessively high rates. Next eliminate option 1 because it is a very low FHR. Review the normal baseline FHR if you had difficulty with this question.

Level of Cognitive Ability: Comprehension
Client Needs: Physiological Integrity
Integrated Process: Communication and Documentation
Content Area: Maternity/Intrapartum
Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 75.

2. A nurse is reinforcing the discharge plan with a female teenager with anorexia nervosa. The nurse reinforces the importance of the teenager attending a meeting of the local chapter of Anorexia Nervosa and Associated Disorders. Which response by the teenager indicates that she will most likely be compliant with this plan?

A. “I’ll go once but if I don’t like it I won’t go back.”
B. “I’ll think about it.”
C. “I’ll do whatever I have to do to get out of this place.”
D. “I’m going to do whatever it takes to get better.”

Answer: D. “I’m going to do whatever it takes to get better.”

Rationale: Self-help groups serve to reduce the possibilities of further emotional distress leading to pathology and necessary treatment. Option 1 indicates that the client already has doubts about participation and has given herself permission to terminate prior to giving it an initial try. Option 2 displays an ambivalent attitude that promises nothing. Option 3 indicates that the client’s thinking is limited to short-term goals. Option 4 shows that the client is a proactive participant in her plan of care.

Test-Taking Strategy: Note the key words most likely in the question. Use the process of elimination, selecting the option that demonstrates the most positive client response in terms of participation. Review the purpose of support groups and the indicators of client compliance with a prescribed treatment plan if you had difficulty with this question.

Level of Cognitive Ability: Analysis
Client Needs: Psychosocial Integrity
Integrated Process: Nursing Process/Evaluation
Content Area: Mental Health
Reference: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis: Mosby, p. 240.

3. A nurse is caring for a 3-hour-old infant and notes that the infant has not eaten since birth, is jittery, and has a weak cry. The mother states that she cannot get the baby to eat. What action should the nurse take first?

A. Let the infant sleep
B. Check the blood glucose level
C. Ask the registered nurse to call the physician immediately
D. Feed the infant

Answer: B. Check the blood glucose level

Rationale: This infant has classic symptoms of hypoglycemia. The nurse should plan to check the infant’s blood glucose level to determine the extent of hypoglycemia, if any, and then to take action by calling the physician or feeding the infant as per the policy of the agency. Permitting the infant to sleep may cause the hypoglycemia to remain untreated and result in neurological damage.

Test-Taking Strategy: Use the process of elimination and note the key word first. Focus on the data in the question to determine that the infant may be experiencing hypoglycemia. This will direct you to option B. Also note that this is the only option that addresses data collection, the first step in the nursing process. Review the signs of hypoglycemia in the infant and appropriate nursing interventions if you had difficulty with this question.

Level of Cognitive Ability: Application
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Maternity/Postpartum
Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 278.

4. A nurse teaches a client how to use an incentive spirometer. Which observation would indicate ineffective use of the spirometer by the client?

A. The client inhales slowly
B. The client forms a tight seal around the mouthpiece with the lips
C. The client is breathing through the nose
D. The client removes the mouthpiece from the mouth to exhale

Answer: C. The client is breathing through the nose

Rationale: Incentive spirometry is not effective if the client breathes through the nose. The client should exhale, form a tight seal around the mouthpiece, inhale slowly, hold to the count of three, and remove the mouthpiece to exhale. The client should repeat the exercise approximately 10 times every hour for best results.

Test-Taking Strategy: Use the process of elimination and note the words “ineffective use.” Visualizing the use of the incentive spirometer will assist in directing you to the correct option. Review this procedure if you had difficulty with this question.

Level of Cognitive Ability: Comprehension
Client Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process/Evaluation
Content Area: Adult Health/Respiratory
Reference: deWit, S. (2005). Fundamental concepts and skills for nursing. Philadelphia: W.B. Saunders, pp. 516-517.

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