Free NCLEX Exam in Multiple Choice 128th Edition

Free NCLEX Exam in Multiple Choice 128th Edition

1. A nurse is caring for a client at risk for postpartum endometritis. Which nursing intervention would minimize this risk following delivery?

A. Instruct the client in proper positioning of the infant to facilitate breast-feeding
B. Encourage early ambulation and the return to daily activities
C. Review hand washing techniques and perineal care with the client
D. Discuss the normal involution process with the client

Answer: C. Review hand washing techniques and perineal care with the client

Rationale: Postpartum endometritis is frequently associated with the invasion of bacteria that may arise from the gastrointestinal tract or from the lower genital tract. Reviewing appropriate hand washing techniques and perineal care with the client during the postpartum period would reduce the risk of possible bacterial invasion of the myometrium. Options 1, 2, and 4 are not specific to minimizing the risk associated with contracting postpartum endometritis.

Test-Taking Strategy: Use the process of elimination and focus on the issue of the question, minimizing the risk of postpartum endometritis. Although all the options listed may promote adaptation of the postpartum client following delivery, option 3 is the most effective in preventing the transmission of organisms into the reproductive tract. Review measures that will minimize the risk of postpartum endometritis if you had difficulty with this question.

Level of Cognitive Ability: Application
Client Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process/Implementation
Content Area: Maternity/Postpartum
Reference: Lowdermilk, D., & Perry, S.E. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, p. 46.

2. A nurse is monitoring a client at risk for postpartum endometritis. Which symptom(s) noted during the first 24 hours after delivery may support this diagnosis?

A. Maternal oral temperature of 100.2° F
B. Uterus two fingerbreadths below midline and firm
C. Abdominal tenderness and chills
D. Increased perspiration and appetite

Answer: C. Abdominal tenderness and chills

Rationale: Symptoms in the postpartum period heralding endometritis include delayed uterine involution, foul-smelling lochia, tachycardia, abdominal tenderness, and temperature elevations up to 104° F. This intrauterine infection may lead to further maternal complications, such as infections of the fallopian tubes, ovaries, and blood (sepsis). Options 1, 2, and 4 represent normal maternal physiological responses in the immediate postpartum period. These changes represent the normal adaptation of reproductive organs (involution) and maternal physiological responses caused by the decreased hormone levels and fluid losses that occur during labor.

Test-Taking Strategy: Use the process of elimination and knowledge regarding the normal and abnormal findings in the postpartum period. This will direct you to option C. Review these symptoms 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/Postpartum
Reference: Lowdermilk, D., & Perry, S.E. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, p. 1047.

3. A nurse is collecting admission data on a client with hepatitis. Which of the following findings would be of most concern to the nurse?

A. Blurred vision or diplopia
B. Urinary frequency or urgency
C. Confusion or drowsiness
D. Diarrhea or constipation

Answer: C. Confusion or drowsiness

Rationale: Hepatitis impairs liver function. If the liver is unable to perform its metabolic and detoxification functions, waste products begin to accumulate in the body. Many of those wastes are protein byproducts, especially ammonia, that are harmful to the central nervous system. Increased ammonia levels are the primary cause of the neurological changes seen in liver disease, beginning first with drowsiness and confusion.

Test-Taking Strategy: Use the process of elimination noting the key words “of most concern.” Use knowledge regarding the pathophysiology associated with hepatitis to direct you to option C. Remember that increased ammonia levels are the primary cause of the neurological changes seen in liver disease, beginning first with drowsiness and confusion. Review the clinical manifestations and complications associated with hepatitis if you had difficulty with this question.

Level of Cognitive Ability: Analysis
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Data Collection
Content Area: Adult Health/Gastrointestinal
Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders,
p. 1340.

4. A nurse is caring for a client recovering from hepatitis. The nurse recognizes the need to report which laboratory test result to the physician?

A. Hepatitis B surface antigen (HBsAg) that is in the normal range
B. Aspartate aminotransferase (AST) that is slightly elevated
C. Delta antigen that is slightly elevated
D. Alanine transaminase (ALT) that is notably elevated

Answer: D. Alanine transaminase (ALT) that is notably elevated

Rationale: As tissue in the body are injured, enzymes present in the cells are released and can be monitored through blood tests. It is important to recognize which enzymes are found in which tissue. AST is found in high concentration in heart muscle and is indicative of heart damage. ALT is found primarily in the liver, and a notably elevated level would indicate liver damage. Antigens are agents that trigger cell damage; antigens do not result from the damage.

Test-Taking Strategy: Use the process of elimination and knowledge regarding the important laboratory findings in hepatitis. Noting the words “notably elevated” in option 4 will direct you to this option as the laboratory result to be reported. Review the laboratory findings in hepatitis if you had difficulty with this question.

Level of Cognitive Ability: Analysis
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Fundamental Skills
Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 721.

Read also:

• NCLEX Exam in Multiple Choice with Answer 127th Edition
• NCLEX Exam in Multiple Choice with Answer 126th Edition
• Free 1000 NCLEX Question & Answer 125th Edition 2020 / 2021

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