NCLEX-RN
Implementation Questions
Extract:
Question 1 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.
Question 2 of 5
The nurse caring for a child who has sustained a head injury notes that the primary health care provider has documented decorticate posturing. During the assessment of the child, the nurse notes the extension of the upper extremities and the internal rotation of the upper arms and wrists. The nurse also notes that the lower extremities are extended, with some internal rotation noted at the knees and feet. On the basis of these findings, what is the initial nursing action?
Correct Answer: D
Rationale: Decorticate (flexion) posturing refers to the flexion of the upper extremities and the extension of the lower extremities. Plantar flexion of the feet may also be observed. Decerebrate (extension) posturing involves the extension of the upper extremities with the internal rotation of the upper arms and wrists. The lower extremities will extend with some internal rotation noted at the knees and feet. The progression from decorticate to decerebrate posturing usually indicates deteriorating neurological function and warrants primary health care provider notification. Although documentation is appropriate, it is not the initial action in this situation. The other options are not appropriate.
Question 3 of 5
The nurse is reviewing the primary health care provider's prescriptions for a child who was admitted to the hospital with vaso-occlusive pain crisis resulting from sickle cell anemia. Which primary health care provider prescription should the nurse question?
Correct Answer: D
Rationale: Meperidine hydrochloride is contraindicated for ongoing pain management because of the increased risk of seizures associated with the use of the medication. The management of vaso-occlusive pain generally includes the use of strong opioid analgesics such as morphine sulfate or hydromorphone. These medications are usually most effective when given as a continuous infusion or at regular intervals around the clock. The remaining options are appropriate prescriptions for treating vaso-occlusive pain crisis.
Question 4 of 5
The nurse prepares to administer an enteral feeding to a client through a nasogastric tube (NGT). Which is the priority intervention for the nurse to complete before administering the feeding?
Correct Answer: A
Rationale: The nurse avoids injecting any substance into a client's NGT before verifying tube placement because NGTs can migrate out of the stomach. If the NGT is not in the correct location, subsequent injections or feedings through the tube can lead to serious complications such as aspiration. None of the remaining options are priorities before administering an enteral feeding.
Question 5 of 5
Which action should the nurse implement as part of care for a client after a bone biopsy?
Correct Answer: D
Rationale: Nursing care after bone biopsy includes monitoring the site for swelling, bleeding, or hematoma formation. The vital signs are monitored every 4 hours for 24 hours. The biopsy site is elevated for 24 hours to reduce edema. A dependent position will increase the risk for bleeding. The client usually requires mild analgesics; more severe pain usually indicates that complications are arising.