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Questions 227

NCLEX-PN

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Extract:

The mother's condition has deteriorated during labor and a cesarean section is required. Her husband is worried and anxious about the changed of plan and demand for an explanation.


Question 1 of 5

Who among the following should explain the procedure to the husband?

Correct Answer: A

Rationale: The surgeon, as the procedure performer, is best suited to explain the cesarean section.

Extract:

You were about to give AM care, a patient requested for pain medication after returning from surgery 24 hours ago.


Question 2 of 5

What do you do first?

Correct Answer: C

Rationale: Vital signs must be assessed before administering pain medication to ensure the patient is stable and to establish a baseline.

Extract:


Question 3 of 5

The nurse is caring for an adult who has ulcerative colitis. When planning care, the nurse knows that which nursing diagnosis is of highest priority?

Correct Answer: A

Rationale: Ulcerative colitis causes diarrhea, leading to fluid loss and dehydration, making deficient fluid volume the highest priority to prevent systemic complications like hypovolemia.

Extract:

The nurse is assigned to a patient newly diagnosed with active tuberculosis.


Question 4 of 5

Which of these interventions would be a priority for the nurse to implement?

Correct Answer: D

Rationale: A negative pressure room and masks prevent airborne transmission of tuberculosis, a priority for infection control.

Extract:


Question 5 of 5

The nurse is administering terbutaline (Brethine) to a client in labor. Prior to administration of the medication, the nurse assesses the client's pulse to be 144. The nurse's priority action should be to

Correct Answer: A

Rationale: Terbutaline, a tocolytic, can cause maternal tachycardia. A pulse of 144 indicates significant tachycardia, a side effect requiring the medication to be withheld to prevent further cardiovascular strain. Decreasing the dose (
B) is not within nursing scope, administering (
C) ignores the risk, and waiting (
D) delays intervention.

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