NCLEX-RN
Health Promotion and Maintenance NCLEX RN Questions Questions
Extract:
Question 1 of 5
A nurse is caring for a 3-day old infant who needs an exchange transfusion. Which of the following statements is appropriate for teaching the child's parents about this procedure?
Correct Answer: B
Rationale: : An exchange transfusion is a method of controlling high bilirubin levels in infants when traditional phototherapy is unsuccessful. During an exchange transfusion, the physician removes 5-10 cc of blood and then replaces it with donor blood. The parents of this infant should know that the procedure is always performed by a physician and will take approximately 1 ½ hours to complete.
Question 2 of 5
A client has entered disseminated intravascular coagulation (DIC) after becoming extremely ill after surgery. Which of the following laboratory findings would the nurse expect to see with this client?
Correct Answer: B
Rationale: In disseminated intravascular coagulation (DI
C), a client experiences widespread clotting throughout the body, leading to the depletion of clotting factors and platelets. A prolonged prothrombin time (PT) is a common finding in DIC. The PT measures the extrinsic pathway of the clotting cascade and reflects how quickly blood can clot. In DIC, the consumption of clotting factors results in a prolonged PT, indicating impaired clotting ability. Elevated fibrinogen levels (
Choice
A) are typically seen in the early stages of DIC due to the body's attempt to compensate for clot breakdown. Elevated platelet count (
Choice
C) is not a typical finding in DIC as platelets are consumed during the widespread clotting. A depressed d-dimer level (
Choice
D) is also not expected in DIC as d-dimer levels are elevated due to the breakdown of fibrin clots.
Therefore, the correct answer is a prolonged PT.
Question 3 of 5
Which of the following situations might warrant a laboratory magnesium level?
Correct Answer: C
Rationale: Ulcerative colitis can lead to symptoms such as abdominal pain, fever, diarrhea, and weight loss. This condition may impact the absorption of certain nutrients, including magnesium.
Therefore, patients with chronic gastrointestinal conditions like ulcerative colitis should be screened for electrolyte imbalances related to impaired digestion. Hyperthyroidism, arthritis, and depression do not typically directly affect magnesium levels in the same way as gastrointestinal conditions like ulcerative colitis.
Question 4 of 5
The nurse caring for a client in labor should plan to assess the fetal heart rate (FHR) at which specific times? Select all that apply.
Correct Answer: A,B,C,E
Rationale: Assessment of the mother and fetus is continuous during the process of labor. However, for all clients, the FHR needs to be assessed before ambulation; immediately after vaginal examinations, rupture of the membranes, or any other invasive procedure; and before the administration of oxytocin because these activities or situations can cause alterations in the FHR. The FHR is also assessed in between contractions, during the contraction, and for at least 30 seconds after the contraction. It is not necessary to assess the FHR before turning the client to her side.
Question 5 of 5
The nurse is teaching a client with atrial fibrillation about the need to begin long-term anticoagulant therapy. Which explanation should the nurse use to best describe the reasoning for this therapy?
Correct Answer: D
Rationale: In atrial fibrillation, the quivering atria cause sluggish blood flow, leading to clot formation along the heart wall, which can dislodge and cause pulmonary or cerebral emboli. Options A, B, and C inaccurately describe the mechanism requiring anticoagulation.