Questions 150

NCLEX-RN

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Question 1 of 5

A diabetic primigravid client at 38 weeks' gestation asks the nurse why she had a fetal acoustic stimulation during her last nonstress test. Which of the following should the nurse include as the rationale for this test?

Correct Answer: B

Rationale: Fetal acoustic stimulation is used to startle and awaken the fetus, prompting movement to assess fetal heart rate reactivity during a nonstress test. It does not directly measure heart rate, stimulate contractions, or assess amniotic fluid.

Question 2 of 5

You are caring for a group of clients who are adversely affected with phobias. Which form of group therapy will you most likely employ to treat these clients?

Correct Answer: C

Rationale: Cognitive behavioral psychotherapy (CBT) is the most effective treatment for phobias, as it combines cognitive restructuring with behavioral techniques like exposure therapy to address irrational fears.

Question 3 of 5

Which of the following serologic tests should the nurse have on the chart before a client is started on tissue plasminogen activator or alteplase recombinant (Activase)?

Correct Answer: A

Rationale: Partial thromboplastin time (PTT) is essential before administering alteplase to assess bleeding risk, as it is a thrombolytic. Potassium levels and other tests are less relevant in this context.

Question 4 of 5

A client with bipolar disorder is admitted during a depressive episode. Which intervention should the nurse prioritize?

Correct Answer: B

Rationale: During a depressive episode, monitoring for suicidal ideation is the priority to ensure client safety, given the high risk of suicide in bipolar depression.

Question 5 of 5

A client diagnosed with refractory myasthenia gravis is told by the primary health care provider that plasmapheresis therapy is indicated. When the client asks the nurse to repeat the primary health care provider's reason for prescribing this treatment, the nurse should tell the client that this therapy will most likely improve which problem?

Correct Answer: B

Rationale: Plasmapheresis is a process that separates the plasma from the blood elements so that plasma proteins that contain antibodies can be removed. It is used as an adjunct therapy in myasthenia gravis and may give temporary relief to clients with actual or impending respiratory failure. Usually 3 to 5 treatments are required. This therapy is not indicated for the reasons listed in any of the other options.

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