NCLEX Questions and Answers pdf 119th Edition

NCLEX Questions and Answers pdf 119th Edition

1. A nurse has delegated care of a client with chronic obstructive pulmonary disease (COPD) to a nursing assistant. The nursing assistant notifies the nurse that the client’s vital signs are elevated, and the client is complaining of pain and dyspnea. Which of the following is appropriate regarding the nurse’s next action?

A. The nurse need not carry out further data collection because the nursing assistant is very experienced and trustworthy
B. The nurse requests that the nursing assistant offer the client an analgesic, which has been prescribed
C. The nurse places a call to the physician and reports the client’s complaints
D. The nurse checks the client and gathers additional data before calling the physician

Answer: D. The nurse checks the client and gathers additional data before calling the physician

Rationale: The nurse must not depend upon the judgment of a nursing assistant because the nurse is responsible for supervising those to whom client care has been delegated. Option 1 is therefore incorrect. Option 2 is inappropriate because this action is not delegated to the nursing assistant. A call to the physician may be warranted, but the nurse has insufficient data at this time, making option 3 incorrect. To provide the client with the degree of care required, the nurse must gather additional information and analyze that information before notifying the physician, making option 4 the correct choice.

Test-Taking Strategy: Use the process of elimination. Eliminate options 1 and 2 because they are similar, indicating that the nurse does not gather any additional data. From the remaining options, option 4 reflects the process of data collection and therefore is the appropriate option. Review the role of the nurse in delegating and supervising tasks delegated to others if you had difficulty with this question.

Level of Cognitive Ability: Application
Client Needs: Safe, Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Delegating/Prioritizing
Reference: deWit, S. (2005). Fundamental concepts and skills for nursing. Philadelphia: W.B. Saunders, pp. 122-123.

2. An outbreak of illness has occurred in a community and is suspected to be related to food ingestion. A nurse is assigned to assist a community health nurse to care for the clients affected by this outbreak. The nurse understands that the initial activity is to:

A. Determine what common food item was ingested by those affected
B. Review the signs and symptoms related to the Salmonella bacteria
C. Involve the Centers for Disease Control and Prevention (CDC)
D. Teach the basic methods for preventing food contamination to those affected

Answer: A. Determine what common food item was ingested by those affected

Rationale: The initial step is to determine what food has been ingested. Option 2 involves teaching and is not the appropriate initial action. Options 3 and 4 involve potential interventions.

Test-Taking Strategy: The key words are initial activity. Use the nursing process to answer the question. The only option that addresses data collection is option A. Review the principles related to community health nursing if you had difficulty with this question.

Level of Cognitive Ability: Application
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Fundamental Skills
Reference: Christensen, B., & Kockrow, E. (2003). Foundations of nursing (4th ed.). St. Louis: Mosby, p. 981.

3. A nurse reviews the antenatal history of a client in early labor. The nurse recognizes that which factor noted in the history presents the greatest potential for causing neonatal sepsis following delivery?

A. Adequate prenatal care
B. Appropriate maternal nutrition and weight gain
C. Spontaneous rupture of membranes 2 hours ago
D. History of substance abuse during pregnancy

Answer: D. History of substance abuse during pregnancy

Rationale: Risk factors for neonatal sepsis can arise from maternal, intrapartal, or neonatal conditions. Maternal risk factors before delivery include low socioeconomic status, poor prenatal care and nutrition, and a history of substance abuse during pregnancy. Premature rupture of the membranes or prolonged rupture of membranes greater than 18 hours before birth is also a risk factor for neonatal acquisition of infection.

Test-Taking Strategy: Use the process of elimination. Options 1 and 2 are optimal findings and present no additional risk. Knowledge of the risk factors helps you accurately select between options 3 and D. Additionally, noting the words “2 hours ago” in option 3, which should assist in eliminating this option. Review the risk factors related to neonatal sepsis if you had difficulty with this question.

Level of Cognitive Ability: Analysis

Clients 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, pp. 282-284.

4. A client who consumes alcohol frequently is in the first trimester of pregnancy. The nurse initiates interventions to assist the client to cease alcohol consumption to:

A. Promote the normal psychosocial adaptation of the mother to pregnancy
B. Reduce the potential for fetal growth restriction in utero
C. Minimize the potential for placental abruptions during the intrapartum period
D. Reduce the risk of teratogenic effects to developing fetal organs, tissue, and structures

Answer: D. Reduce the risk of teratogenic effects to developing fetal organs, tissue, and structures

Rationale: The first trimester, “organogenesis,” is characterized by the differentiation and development of fetal organs, systems, and structures. The effects of alcohol on the developing fetus during this crucial period depend, not only on the amount of alcohol consumed, but on the interaction of quantity, frequency, type of alcohol, and other drugs that may be abused during this period by the pregnant woman.

Test-Taking Strategy: Use the process of elimination and focus on the issue of the question, the purpose of ceasing alcohol consumption. Option 4 specifically relates to the issue of the question. Also, recalling that the first trimester is characterized by the differentiation and development of fetal organs, systems, and structures will direct you to option D. If you had difficulty with this question, review the effects of alcohol on the fetus in the first trimester of pregnancy.

Level of Cognitive Ability: Comprehension
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Maternity/Antepartum
Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 11D.

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