NCLEX-RN
Implementation Questions
Extract:
Question 1 of 5
The nurse is caring for a client who is scheduled an arthrogram involving the use of a contrast medium. Which action by the nurse is the priority?
Correct Answer: A
Rationale: Because of the risk of allergy to contrast medium, the nurse places the highest priority on assessing whether the client has an allergy to iodine or shellfish. The nurse also reinforces information about the test and reminds the client about the need to remain still during the procedure. It is helpful to have the client void before the procedure for comfort.
Question 2 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 3 of 5
A client tells the clinic nurse that her skin is very dry and irritated. Which product should the nurse suggest that the client apply to the dry skin?
Correct Answer: C
Rationale: A topical emollient is used for dry, cracked, and irritated skin. Aspercreme and Myoflex are used to treat muscular aches. Acetic acid solution is used for irrigating, cleansing, and packing wounds infected with Pseudomonas aeruginosa.
Question 4 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.
Question 5 of 5
The mother of the child with a diagnosis of hepatitis B calls the health care clinic to report that the jaundice seems to be worsening. Which response should the nurse make to the mother?
Correct Answer: C
Rationale: The parents should be instructed that jaundice may appear to get worse before it resolves. The parents of a child with hepatitis should also be taught the danger signs that could indicate a worsening of the child's condition, specifically changes in neurological status, bleeding, and fluid retention. Based on this information, the statements in the remaining options are incorrect.