NCLEX-PN
Health Promotion and Maintenance NCLEX Questions Questions
Extract:
Question 1 of 5
A nurse notes the presence of variable decelerations on the fetal heart rate monitor strip and suspects cord compression. The nurse should immediately perform which action?
Correct Answer: B
Rationale: When variable decelerations on the fetal heart rate monitor strip suggest cord compression, the immediate action the nurse should take is to reposition the mother to alleviate the compression. Elevating the mother's hips or changing her position can help shift the fetal presenting part and relieve pressure on the cord. This action aims to improve or resolve the variable decelerations. Contacting the registered nurse may be necessary, but it is not the immediate action required in this situation. Performing a vaginal examination is contraindicated due to the potential risk of further compromising blood flow through the umbilical cord. Inserting a gloved finger into the mother's vagina to feel for the cord is also not recommended as it poses a similar risk of exacerbating the situation.
Question 2 of 5
The physician wants to know if a client is tolerating his total parenteral nutrition. Which of the following laboratory tests is likely to be ordered?
Correct Answer: B
Rationale: The liver is the primary organ for digestion. Liver function tests measure the blood level of enzymes produced by the liver to assess tolerance of total parenteral nutrition.
Question 3 of 5
An Rh-negative woman with previous sensitization has delivered an Rh-positive fetus. Which of the following nursing actions should be included in the client's care plan?
Correct Answer: A
Rationale: In this scenario, the Rh-negative woman has been sensitized, posing a risk to any Rh-positive fetus she delivers. The most appropriate nursing action is to provide emotional support to help the family cope with the infant's condition. This includes addressing potential outcomes like death or neurological damage. Administering MICRhoGam (
Choice
B) to a sensitized woman is not recommended; it is only given post-abortion or ectopic pregnancy to prevent sensitization. Rh-immune globulin is not administered to the newborn (
Choice
C) in this case. Analyzing the maternal Direct Coombs' test (
Choice
D) is unnecessary; instead, an Indirect Coombs' test is used to assess sensitization.
Therefore, the correct nursing action is to offer emotional support to the family, acknowledging the challenges they may face.
Question 4 of 5
Distribution of a drug to various tissues is dependent on the amount of cardiac output to each type of tissue. Which tissue would receive the highest amount of cardiac output and thus the highest amount of a drug?
Correct Answer: D
Rationale: Highly perfused tissue includes all vital organs: the brain, heart, kidneys, adrenal glands, and liver.
Choices 1, 2, and 3 are incorrect because the skin and adipose tissue are poorly perfused, while the skeletal muscle is better perfused.
Question 5 of 5
A nurse assisting with data collection is preparing to auscultate for bowel sounds. The nurse should use which technique?
Correct Answer: A
Rationale:
To auscultate for bowel sounds, the nurse should use the diaphragm end piece of the stethoscope as bowel sounds are relatively high pitched. The stethoscope should be held lightly against the skin to avoid stimulating more bowel sounds. The nurse should begin in the right lower quadrant at the ileocecal valve, where bowel sounds are normally present. It is recommended to listen for 5 minutes before deciding that bowel sounds are absent to ensure a thorough assessment.
Choice B is incorrect because the bell end is used for low-pitched sounds such as heart sounds.
Choice C is incorrect as holding the stethoscope firmly and deeply can cause unnecessary bowel sound stimulation.
Choice D is incorrect as listening for 1 minute is insufficient to determine the presence or absence of bowel sounds.