NCLEX-RN Practice Test 20
As the client reaches 8 cm dilation, the nurse notes late decelerations on the fetal monitor. The FHR baseline is 165–175 bpm with variability of 0–2bpm. What is the most likely explanation of this pattern?
This information indicates a late deceleration. This type of deceleration is caused by uteroplacental lack of oxygen. Option A: Has no relation to the readings. Option B: Compressed umbilical cord results in a variable deceleration. Option C: A vagal response is indicative of an early deceleration.
A client in the family planning clinic asks the nurse about the most likely time for her to conceive. The nurse explains that conception is most likely to occur when:
Luteinizing hormone released by the pituitary is responsible for ovulation. At about day 14, the continued increase in estrogen stimulates the release of luteinizing hormone from the anterior pituitary. The LH surge is responsible for ovulation, or the release of the dominant follicle in preparation for conception, which occurs within the next 10–12 hours after the LH levels peak. Options A, C, and D: Estrogen levels are high at the beginning of ovulation, the endometrial lining is thick, not thin, and the progesterone levels are high, not low.
A client tells the doctor that she is about 20 weeks pregnant. The most definitive sign of pregnancy is:
The most definitive diagnosis of pregnancy is the presence of fetal heart tones. The signs in answers A, C, and D are subjective and might be related to other medical conditions. Options A and C: Elevated human chorionic gonadotropin and uterine enlargement may be related to a hydatidiform mole. Option D: Breast enlargement and tenderness is often present before menses or with the use of oral contraceptives.
In evaluating the effectiveness of IV Pitocin for a client with secondary dystocia, the nurse should expect:
The expected effect of Pitocin is cervical dilation. Option A: Pitocin causes more intense contractions, which can increase the pain. Option B: Cervical effacement is caused by pressure on the presenting part. Option C: Infrequent contractions is opposite the action of Pitocin.
The home health nurse is planning for the day’s visits. Which client should be seen first?
The client at highest risk for complications is the client with multiple sclerosis who is being treated with cortisone via the central line. The others are more stable. MRSA is Methicillin-Resistant Staphylococcus Aureus. Vancomycin is the drug of choice and is given at scheduled times to maintain blood levels of the drug. Options A, B, and C: These clients are more stable and can be seen later.
A client tells the nurse that she plans to use the rhythm method of birth control. The nurse is aware that the success of the rhythm method depends on the:
The success of the rhythm method of birth control is dependent on the client’s menses being regular. Options A, B, and D: It is not dependent on the age of the client, frequency of intercourse, or range of the client’s temperature.
The client with hyperemesis gravidarum is at risk for developing:
The client with hyperemesis has persistent nausea and vomiting. With vomiting comes dehydration. When the client is dehydrated, she will have metabolic acidosis. Options A and C are incorrect because they are respiratory dehydration. Option D is incorrect because the client will not be in alkalosis with persistent vomiting.
A client telephones the emergency room stating that she thinks that she is in labor. The nurse should tell the client that labor has probably begun when:
The client should be advised to come to the labor and delivery unit when the contractions are every 5 minutes and consistent. She should also be told to report to the hospital if she experiences rupture of membranes or extreme bleeding. Options A and B: She should not wait until the contractions are every 2 minutes or until she has a bloody discharge. Option C: Has a vague answer and can be related to a urinary tract infection.
The emergency room is flooded with clients injured in a tornado. Which clients can be assigned to share a room in the emergency department during the disaster?
The pregnant client and the client with a broken arm and facial lacerations are the best choices for placing in the same room. Options A, C, and D: The following group of clients needs to be placed in separate rooms due to the serious nature of their injuries.
She decides to illustrate the organizational structure. Which of the following elements is NOT included?
Unity of direction is a management principle, not an element of an organizational structure.
She plans of assigning competent people to fill the roles designed in the hierarchy. Which process refers to this?
Staffing is a management function involving putting the best people to accomplish tasks and activities to attain the goals of the organization.
She checks the documentary requirements for the applicants for staff nurse position. Which one is NOT necessary?
Record of RLE is not required for employment purposes but it is required for the nurse’s licensure examination.
Which phase of the employment process includes getting on the payroll and completing documentary requirements?
This step in the recruitment process gives time for the staff to submit all the documentary requirements for employment.
She tries to design an organizational structure that allows communication to flow in all directions and involve workers in decision making. Which form of organizational structure is this?
Decentralized structures allow the staff to make decisions on matters pertaining to their practice and communicate in downward, upward, lateral and diagonal flow.
In a horizontal chart, the lowest level worker is located at the
The leftmost box is occupied by the highest authority while the lowest level worker occupies the rightmost box.
She decides to have a decentralized staffing system. Which of the following is an advantage of this system of staffing?
Decentralized structures allow the staff to solve decisions by themselves, involve them in decision making; hence they are always given opportunities to interact with one another.