NCLEX-RN
Evaluation Questions
Extract:
Question 1 of 5
A woman in labor is receiving oxytocin by intravenous infusion. The nurse monitors the client, knowing that which finding indicates an adequate contraction pattern?
Correct Answer: D
Rationale: The preferred oxytocin dosage is the minimal amount necessary to maintain an adequate contraction pattern characterized by 3 to 5 contractions in a 10-minute period, with resultant cervical dilation. If contractions are more frequent than every 2 minutes, contraction quality may be decreased.
Question 2 of 5
The nurse is monitoring a male client with a spinal cord injury who is experiencing spinal shock. Which findings indicate that the spinal shock is resolving?
Correct Answer: C,D,E,F
Rationale: Spinal shock is associated with acute injury to the spinal cord with temporary suppression of reflexes controlled by segments below the level of injury. It may last for 1 to 6 weeks. Indications that spinal shock is resolving include return of reflexes, development of hyperreflexia rather than flaccidity, and return of reflex emptying of the bladder. The return of the bulbocavernous reflex in male clients is also an early indicator of recovery from spinal shock. Babinski's reflex (dorsiflexion of the great toe with fanning of the other toes when the sole of the foot is stroked) is an early returning reflex. The gag reflex is not lost in spinal shock; therefore, its presence is not an indication of resolving spinal shock.
Question 3 of 5
The nurse reviews the nursing care plan of a hospitalized preschool child who is immobilized as a result of skeletal traction. The nurse notes concerns related to the child's development because of immobilization and hospitalization. Which evaluative statement indicates a positive outcome for the child?
Correct Answer: D
Rationale: Regression and inappropriate developmental behaviors may be displayed in response to immobilization and hospitalization. With individualized care planning, a positive outcome of age-appropriate behavior can be achieved. The remaining options are appropriate evaluative statements for an immobilized child, but they do not directly address the child's development.
Question 4 of 5
A 24-hour-old term infant had a confirmed episode of hypoglycemia when 1 hour old. Which observation by the nurse would indicate the need for follow-up?
Correct Answer: D
Rationale: Hypoglycemia causes central nervous system symptoms (high-pitched cry), and it is also exhibited by a lack of strength for eating enough for growth. At 24 hours old, a term infant should be able to consume at least 1 ounce of formula per feeding. A high-pitched cry is indicative of neurological involvement. Weight loss over the first few days of life and dry, peeling skin are normal findings for term infants. Blood glucose levels are acceptable at 40 \mathrm{mg} / \mathrm{dL}(2.28 \mathrm{mmol} / \mathrm{L}) during the first few days of life.
Question 5 of 5
The nurse has provided discharge instructions to the parent of a child who has undergone heart surgery. Which statement by the parent would indicate the need for further instruction?
Correct Answer: A
Rationale: The child may return to school the third week after hospital discharge, but he or she should go to school for half days for the first week. Outside play should be omitted for several weeks, with inside play allowed as tolerated. The child should avoid crowds of people for 2 weeks after discharge, including crowds at day care centers and churches. If any difficulty with breathing occurs, the parent should notify the primary health care provider.