NCLEX-RN
Implementation Questions
Extract:
Question 1 of 5
A client admitted to the hospital with a diagnosis of a leaking cerebral aneurysm is scheduled for surgery. Which intervention should the nurse implement during the preoperative period?
Correct Answer: A
Rationale: The client is placed on aneurysm precautions, and the client's activity is kept to a minimum to prevent Valsalva's maneuver. Clients often hold their breath and strain while pulling up to get out of bed. This exertion may cause a rise in blood pressure, which increases bleeding. Clients who have bleeding aneurysms in any vessel will have activity curtailed.
Therefore, the rest of the options are incorrect actions.
Question 2 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 3 of 5
The nurse is preparing to suction a tracheotomy on an infant. The nurse prepares the equipment for the procedure and should turn the suction to which setting?
Correct Answer: B
Rationale: The suctioning procedure for pediatric clients varies from that used for adults. Suctioning in infants and children requires the use of a smaller suction catheter and lower suction settings as compared with those used for adults. Suction settings for a neonate are usually 60 to 80 mm Hg; for an infant, 80 to 100 mm Hg; and, for larger children, 100 to 120 mm Hg. The primary health care provider prescription and agency procedures are always followed.
Question 4 of 5
Which is the most important laboratory result for the nurse to present to the primary health care provider on a client who is receiving total parenteral nutrition (TPN)?
Correct Answer: B
Rationale: Serum electrolyte levels are critical to monitor in a client receiving TPN because TPN solutions contain high concentrations of glucose and electrolytes, which can lead to imbalances such as hyperkalemia, hypokalemia, or hyponatremia. These imbalances can cause serious complications, including cardiac dysrhythmias or neurological issues. While white blood cell count, arterial blood gas levels, and hemoglobin and hematocrit levels are important, they are not as directly related to the immediate risks associated with TPN administration as electrolyte levels.
Question 5 of 5
A primipara is being evaluated in the clinic during her second trimester of pregnancy. The nurse checks the fetal heart rate (FHR) and notes that it is 190 beats/min. What is the appropriate initial nursing action?
Correct Answer: C
Rationale: The FHR should be between 120 and 160 beats/min. In this situation, the FHR is elevated from the normal range, and the nurse should consult with the primary health care provider. The FHR would be documented, but option 3 is the appropriate action. The nurse would not tell the client that the FHR is fast at this point in time. Option 4 is an inappropriate action.