NCLEX-RN Practice Test 23
The physician has ordered an injection of RhoGam for the postpartum client whose blood type is A negative but whose baby is O positive. To provide postpartum prophylaxis, RhoGam should be administered:
To provide protection against antibody production, RhoGam should be given within 72 hours. Options B, C, and D: These durations are too late to provide antibody protection. RhoGam can also be given during pregnancy.
The nurse notes variable decelerations on the fetal monitor strip. The most appropriate initial action would be to:
The initial action by the nurse observing a late deceleration should turn the client to the side—preferably, the left side. Administering oxygen is also indicated. Option A: Notifying the physician might be necessary but not before turning the client to her side. Option B: Starting an IV is not necessary at this time. Option D: Readjusting the fetal monitor is inappropriate since there is no data to indicate that the monitor has been applied incorrectly.
A client is admitted to the labor and delivery unit complaining of vaginal bleeding with very little discomfort. The nurse’s first action should be to:
The symptoms of painless vaginal bleeding are consistent with placenta previa. Option B: Cervical check for dilation is contraindicated because this can increase the bleeding. Option C: Checking for firmness of the uterus can be done, but the first action should be to check the fetal heart tones. Option D: A detailed history can be done later.
The nurse is caring for a client admitted with epiglottitis. Because of the possibility of complete obstruction of the airway, which of the following should the nurse have available?
For a child with epiglottitis and the possibility of complete obstruction of the airway, emergency tracheostomy equipment should always be kept at the bedside. Options A, C, and D: Intravenous supplies, fluid, and oxygen will not treat an obstruction.
A child is admitted to the hospital with a diagnosis of Wilms tumor, stage II. Which of the following statements most accurately describes this stage?
The staging of Wilm’s tumor is confirmed at surgery as follows: Stage I, the tumor is limited to the kidney and completely resected; stage II, the tumor extends beyond the kidney but is completely resected; stage III, residual non hematogenous tumor is confined to the abdomen; stage IV, hematogenous metastasis has occurred with spread beyond the abdomen; and stage V, bilateral renal involvement is present at diagnosis.
A child has recently been diagnosed with Duchenne’s muscular dystrophy. The parents are receiving genetic counseling prior to planning another pregnancy. Which of the following statements includes the most accurate information?
The recessive Duchenne’s gene is located on one of the two X chromosomes of a female carrier. If her son receives the X bearing the gene he will be affected. Thus, there is a 50% chance of a son being affected. Daughters are not affected, but 50% are carriers because they inherit one copy of the defective gene from the mother. The other X chromosome comes from the father, who cannot be a carrier.
The client is admitted for an open reduction internal fixation of a fractured hip. Immediately following surgery, the nurse should give priority to assessing the:
Bleeding is a common complication of orthopedic surgery. The blood-collection device should be checked frequently to ensure that the client is not hemorrhaging. Option B: The client’s pain should be assessed, but this is not life-threatening. Options C and D: When the client is in less danger, the nutritional status should be assessed and an immobilizer is not used.
The nurse is assigned to care for the client with a Steinmann pin. During pin care, she notes that the LPN uses sterile gloves and Q-tips to clean the pin. Which action should the nurse take at this time?
The nurse is performing the pin care correctly when she uses sterile gloves and Q-tips. Options B, C, and D: A licensed practical nurse can perform pin care, there is no need to clean the weights, and the nurse can help with opening the packages but it isn’t required.
The elderly client is admitted to the emergency room. Which symptom is the client with a fractured hip most likely to exhibit?
The client with a hip fracture will most likely have misalignment. Options A, C, and D: All fractures cause pain, and coolness of the extremities and absence of pulses are indicative of compartment syndrome or peripheral vascular disease.
He knows that there are external forces that influence changes in his unit. Which of the following is NOT an external force?
Low morale of staff is an internal factor that affects only the unit. All the rest of the options emanate from the top executive or from outside the institution.
After discussing the possible effects of the low patient satisfaction rate, the staff started to list down possible strategies to solve the problems head-on. Should they decide to vote on the best change strategy, which of the following strategies is referred to this?
Majority rule involves dividing the house and the highest vote wins.1/2 + 1 is a majority.
One staff suggests that they review the pattern of nursing care that they are using, which is described as a:
A system used to deliver care. In the 70’s it was termed as methods of patient assignment; in the early 80’s it was called modalities of patient care then patterns of nursing care in the 90’s until recently authors called it nursing care systems.
Which of the following is TRUE about functional nursing?
Functional nursing is focused on tasks and activities and not on the holistic care of the patients
He raised the issue on giving priority to patient needs. Which of the following offers the best way for setting priority?
This option follows the framework of the nursing process at the same time applies the management process of planning, organizing, directing and controlling
Which of the following is the best guarantee that the patient’s priority needs are met?
The best source of information about the priority needs of the patient is the patient himself. Hence using a nursing care plan based on his expressed priority needs would ensure meeting his needs effectively.
When Henry uses team nursing as a care delivery system, he and his team need to assess the priority of care for a group of patients, which of the following should be a priority?
In setting priorities for a group of patients, those who need the most care should be number-one priority to ensure that their critical needs are met adequately. The needs of other patients who need less care ca be attended to later or even delegated to assistive personnel according to rules on delegation.