NCLEX-RN
Implementation Questions
Question 1 of 5
A client in the second trimester of pregnancy is being assessed at the primary health care clinic. The nurse notes that the fetal heart rate (FHR) is 100 beats/min. Which nursing action would be appropriate initially?
Correct Answer: B
Rationale: The FHR should be between 120 and 160 beats/min during pregnancy. An FHR of 100 beats/min would require that the primary health care provider be notified and the client be further evaluated. Although the nurse would document the findings, the most appropriate nursing action is to notify the primary health care provider. Based on this information, eliminate the options that suggest inaccurate nursing actions.
Question 2 of 5
The nurse is asked to assist another health care team member with providing care for a client. On entering the client's room, the nurse notes that the client is placed in this position (refer to figure). After maintaining the client position, what should the nurse interpret that this client is most likely being treated for?
Correct Answer: A
Rationale: A client in shock is placed in a modified Trendelenburg's position that includes elevating the legs, leaving the trunk flat, and elevating the head and shoulders slightly. This position promotes increased venous return from the lower extremities without compressing the abdominal organs against the diaphragm. The Trendelenburg position is no longer recommended for hypotensive clients because the client is predisposed to aspiration and worsens gas exchange. The remaining options identify conditions in which the head of the client's bed would be elevated.
Question 3 of 5
A client who has experienced a stroke has episodes of coughing while swallowing liquids. The client has developed a temperature of 101°F (38.3°C) and an oxygen saturation of 91% (down from 98% previously), is slightly confused, and has noticeable dyspnea. Which action should the nurse take?
Correct Answer: A
Rationale: The client is exhibiting clinical signs and symptoms of aspiration, which include fever, dyspnea, decreased arterial oxygen levels, and confusion. Other symptoms that occur with this complication are difficulty with managing saliva or coughing or choking while eating. Because the client has developed a complication that requires medical intervention, the most appropriate action is to contact the primary health care provider. The remaining options are not related to the management of aspiration.
Question 4 of 5
The nurse prepares to admit a newborn born with spina bifida, myelomeningocele. Which nursing action is most important for the care for this infant?
Correct Answer: C
Rationale: Intracranial pressure is a complication that is associated with spina bifida. A sign of intracranial pressure in the newborn infant with spina bifida is a bulging anterior fontanel. The newborn infant is at risk for infection before the surgical procedure and the closure of the gibbus, and monitoring the temperature is an important intervention; however, assessing the anterior fontanel for bulging is most important. A normal saline dressing is placed over the affected site to maintain the moisture of the sac and its contents. This prevents tearing or breakdown of skin integrity at the site. Blood pressure is difficult to assess during the newborn period, and it is not the best indicator of infection or a potential complication. Urine concentration is not well developed during the newborn stage of development.
Question 5 of 5
The nurse is caring for a hospitalized 14-year-old child who is placed in Crutchfield traction. The child is having difficulty adjusting to the length of the hospital confinement. Which nursing action would be appropriate to meet the child's needs?
Correct Answer: B
Rationale: An adolescent needs to identify with peers and has a strong need to belong to a group. The child should be allowed to wear his or her own clothes to feel a sense of belonging to the group. The adolescent likes to dress like the group and to wear similar hairstyles. Loud music may disturb others in the hospital. Because Crutchfield traction involves the use of skeletal pins, hair dye is not appropriate. The child's request for a darkened room is indicative of a possible problem with depression that may require further evaluation and intervention.