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Questions 157

NCLEX-RN

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Question 1 of 5

The day following his admission, the nurse sits down by a male client on the sofa in the dayroom. He was admitted for depression and thoughts of suicide. He looks at the nurse and says, 'My life is so bad no one can do anything to help me.' The most helpful initial response by the nurse would be:

Correct Answer: C

Rationale: This response does not acknowledge the client's feelings and may increase his feelings of guilt. This response denotes false reassurance. This response acknowledges the client's feelings and invites a response. This response changes the subject and does not allow the client to talk about his feelings.

Question 2 of 5

The nurse is caring for a client with a history of Rh sensitization. The physician orders a Kleihauer-Betke test. The purpose of this test is to:

Correct Answer: A

Rationale: The Kleihauer-Betke test quantifies fetal blood in maternal circulation critical in Rh sensitization to determine the dose of RhoGAM needed to prevent maternal antibody formation. It does not assess lung maturity antibodies or amniotic fluid volume.

Question 3 of 5

A child is to receive atropine 0.15 mg (1/400 g) as part of his preoperative medication. A vial containing atropine 0.4 mg (1/150 g)/mL is on hand. How much atropine should be given?

Correct Answer: B

Rationale: The answer is correct. 0.4 mg = 1 mL : 0.15 mg = x mL, 0.4x = 0.15, x = 0.15 / 0.4, x = 0.375 or 0.38 mL. Sufficient information is provided to determine the amount of atropine to administer. The amount of atropine available and the amount of atropine ordered is required to determine the amount of atropine to be given.

Question 4 of 5

As the client reaches 6cm dilation,the nurse notes late decelerations on the fetal monitor. What is the most likely explanation of this pattern?

Correct Answer: D

Rationale: Late decelerations indicate uteroplacental insufficiency where reduced placental blood flow during contractions causes fetal hypoxia. Cord compression causes variable decelerations head compression causes early decelerations and sleep does not cause decelerations.

Question 5 of 5

The nurse is caring for a client with a diagnosis of postpartum depression. Which intervention is most appropriate?

Correct Answer: B

Rationale: Postpartum depression benefits from psychosocial interventions like support groups which provide emotional support and coping strategies. Magnesium sulfate antibiotics and physical activity are not specific treatments for postpartum depression.

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