Blog about quiz / question and answer NCLEX (National Council Licensure Examination) For Nursing Student, Example Question NCLEX RN and NCLEX PN. Exam for Nurse
1. A 32-week gestation woman is brought into the emergency room after an automobile accident. The client is bleeding vaginally, and fetal assessment indicates moderate fetal distress. What will the nurse plan to do first in an attempt to reduce the stress on the fetus?
A. Maintain intravenous fluids at a keep-open rate
B. Administer oxygen with a facemask at 7 to 10 L/min
C. Elevate the head of the bed to a semi-Fowler position
D. Set up for an immediate cesarean delivery
Answer: B. Administer oxygen with a facemask at 7 to 10 L/min
Rationale: Administering oxygen will increase the amount of oxygen for transport to the fetus. This action is essential regardless of the cause or amount of bleeding. Although options 1, 3, and 4 may be necessary at some point during the care of the client, they are not the priority. Additionally, there is no data in the question that indicates that an immediate cesarean delivery is necessary.
Test-Taking Strategy: Use the process of elimination and note the key words moderate fetal distress. Using the ABCs—airway, breathing, and circulation—guides you to option B. Review the measures to reduce the stress on the fetus if you had difficulty with this question.
Level of Cognitive Ability: Application
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Maternity/Antepartum
Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed.). St. Louis: Elsevier, pp. 390, 660.
2. A physician orders the deflation of the esophageal balloon of a Sengstaken-Blakemore tube in a client. The nurse assisting in caring for the client monitors the client closely knowing that following the deflation, this client may be at risk for:
A. Increased ascites
B. Esophageal necrosis
C. Hemorrhaging again from the esophageal varices
D. Esophageal rupture
Answer: C. Hemorrhaging again from the esophageal varices
Rationale: A Sengstaken-Blakemore tube is inserted in cirrhosis clients with ruptured esophageal varices. It has esophageal and gastric balloons. The esophageal balloon exerts pressure on the ruptured esophageal varices and stops the bleeding. The pressure of the esophageal balloon is released at intervals to decrease the risk of trauma to the esophageal tissue, including esophageal rupture or necrosis. When the balloon is deflated, the client may begin to bleed again from the esophageal varices.
Test-Taking Strategy: Use the process of elimination. Remembering that the esophageal balloon exerts pressure on the ruptured esophageal varices and stops the bleeding will assist in directing you to the correct option. Review the complications associated with this type of tube if you are unfamiliar with them.
Level of Cognitive Ability: Application
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Adult Health/Gastrointestinal
Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 228.
3. A nurse assists the cardiac client to identify resources to help her care for her 18-month-old child during the last trimester of pregnancy. The nurse also encourages the client to use breathing and relaxation techniques twice a day. The purpose of these strategies is to:
A. Help the client prepare for labor and delivery
B. Reduce excessive maternal stress and fatigue
C. Prepare the 18-month-old child for maternal separation during hospitalization
D. Avoid exposure to potential pathogens and resulting infections
Answer: B. Reduce excessive maternal stress and fatigue
Rationale: A variety of factors can cause increased emotional stress during pregnancy, resulting in further cardiac complications. The client with known cardiac disease is at greater risk for such complications. The strategies identified in this question would primarily reduce excessive maternal stress and fatigue. Options 1, 3, and 4 are not the purpose of these strategies.
Test-Taking Strategy: Use the process of elimination focusing on the issue of the question, the purpose of these strategies in a pregnant client with cardiac disease. Recalling the needs of the pregnant client with cardiac disease will direct you to option B. Review these strategies if you had difficulty with this question.
Level of Cognitive Ability: Comprehension
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. 225.
4. A nurse is collecting data on a pregnant client. The nurse includes which question to determine if the client is at risk for toxoplasmosis parasite infection during pregnancy?
A. “How many sexual partners have you had during the pregnancy?”
B. “Have you experienced any high fevers or unusual rashes during the first 6 weeks of your pregnancy?”
C. “Have you been exposed to children with rashes or gastrointestinal symptoms?”
D. “Do you have any cats at home, and do you handle the kitty litter?”
Answer: D. “Do you have any cats at home, and do you handle the kitty litter?”
Rationale: Toxoplasmosis is a systemic, usually asymptomatic illness, caused by the protozoan parasite. Humans acquire the infection from inadequately cooked meat, eggs, or milk; ingesting or inhaling the oocyst stage of the parasite excreted in feline feces in contaminated soil; or from contaminated blood-product transmission. Other than transplacental infection, this disease is rarely transmitted from human to human. During pregnancy, the parasite may be transmitted across the placenta and cause severe infection to the developing embryo or fetus.
Test-Taking Strategy: Use the process of elimination. Recalling the transmission of toxoplasmosis will easily direct you to option D. Remember that humans acquire the infection from inadequately cooked meat, eggs, or milk; ingesting or inhaling the oocyst stage of the parasite excreted in feline feces in contaminated soil; or from contaminated blood-product transmission. Review the cause of this infection if you had difficulty with this question.
Level of Cognitive Ability: Comprehension
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Data Collection
Content Area: Maternity/Intrapartum
Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 110.
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