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Questions 158

NCLEX-RN

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Question 1 of 5

After performing a sterile vaginal exam on a client who has just been admitted to the unit in active labor and placed on an electronic fetal monitor, the RN assesses that the fetal head is at 21 station. She documents this on the monitor strip. Fetal head at 21 station means that the fetal head is located where in the pelvis?

Correct Answer: B

Rationale: Station refers to the relationship of the presenting part to the ischial spines. A station of -1 indicates the fetal head is 1 cm above the ischial spines.

Question 2 of 5

A client with a history of atrial flutter is admitted with complaints of dizziness. The nurse should give priority to:

Correct Answer: A

Rationale: Atrial flutter causes rapid heart rates, which can lead to dizziness due to reduced cardiac output, so monitoring heart rate is the priority.

Question 3 of 5

Discharge teaching was effective if the parents of a child with atopic dermatitis could state the importance of:

Correct Answer: D

Rationale: Maintaining a low-humidified environment. Avoiding furry, soft stuffed animals for play, which may increase symptoms of allergy. Avoiding showering, which irritates the dermatitis, and encouraging bathing 4 times a day in colloid bath for temporary relief. Wrapping hands in soft cotton gloves to prevent skin damage during scratching.

Question 4 of 5

A 3-year-old child is admitted with a diagnosis of possible noncommunicating hydrocephalus. What is the first symptom that indicates increased intracranial pressure?

Correct Answer: C

Rationale: Headache is the earliest symptom of increased intracranial pressure in children, preceding other signs like seizures or ataxia.

Question 5 of 5

Seven days ago, a 45-year-old female client had an ileostomy. She is self-sufficient and well otherwise. Which of the following long-term objectives would be unrealistic?

Correct Answer: A

Rationale: Because of the location of an ileostomy, the client will not be able to control the evacuation of her bowels. The ileostomy will drain liquid stool continuously. The client should be able to return to a normal, well-balanced diet. She should avoid foods that cause diarrhea or excessive gas production, and she should eat small meals. The client should be able to resume sexual activity. She will be able to wear a pouch. The client has no other health or mental problems and should be able to manage her own ileostomy.

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