NCLEX-RN
Implementation Questions
Extract:
Question 1 of 5
A client in the late, active, first stage of labor has just reported a gush of vaginal fluid. The nurse observes a fetal monitor pattern of variable decelerations during contractions followed by a brief acceleration. After that, there is a return to baseline until the next contraction, when the pattern is repeated. On the basis of these data, what is the nurse's initial intervention?
Correct Answer: C
Rationale: Variable deceleration with brief acceleration after a gush of amniotic fluid is a common clinical manifestation of cord compression caused by occult or frank prolapse of the umbilical cord. A manual vaginal exam can detect the presence of the cord in the vagina, which confirms the problem. On the basis of the data in the question, none of the remaining options are initial actions.
Question 2 of 5
A client begins to experience seizure activity while in bed. The nurse should provide which intervention to prevent aspiration?
Correct Answer: D
Rationale: Positioning the client on one side with the head flexed forward allows the tongue to fall forward and facilitates the drainage of secretions, which could help prevent aspiration. The nurse would not raise the head of the client's bed. The nurse would remove restrictive clothing and the pillow and raise the padded side rails, if present, but these actions would not decrease the risk of aspiration; rather, they are general safety measures to use during seizure activity.
Question 3 of 5
A pregnant client is receiving rehabilitative services for alcohol abuse. How should the nurse provide supportive care?
Correct Answer: A,C,D,E
Rationale: The nurse provides supportive care by encouraging the client to participate in care and to identify coping strategies. Counseling needs to continue after the infant is born. Communication with family members is important but not when they are supporting the addiction. It is not appropriate to suggest adoption.
Question 4 of 5
During the assessment, the nurse notes that the child's genitals are swollen. The nurse suspects that the child is being sexually abused. Which action by the nurse is of primary importance?
Correct Answer: B
Rationale: The primary legal responsibility of the nurse when child abuse is suspected is to report the case. All 50 states require health care professionals to report all cases of suspected abuse. Although documenting the assessment findings, assisting the family, and referring the family to appropriate resources and support groups is important, the primary legal responsibility is to report the case. Although the remaining options are appropriate, reporting the findings has priority.
Question 5 of 5
The nurse prepares for a client in leg traction to be admitted to the nursing unit. The nurse asks the unlicensed assistive personnel to obtain which essential item that will be needed to assist the client to move in bed while in leg traction?
Correct Answer: C
Rationale: A trapeze is essential to allow the client to lift straight up while being moved so that the amount of pull exerted on the limb in traction is not altered. A foot board and extra pillows do not facilitate moving. Either an electric bed or a manual bed can be used for traction, but this does not specifically assist the client with moving in bed.