NURSING SURGICAL NCLEX-PN HESI NGN Comp Practice Exam answered Questions Assured success A+
When caring for a client in labor, which finding is most important to report to the primary health care provider?
A.Maternal heart rate, 90 beats/min.
B.Fetal heart rate, 100 beats/min
C.Maternal bl...
When caring for a client in labor, which finding is most important to report to
the primaryhealth care provider?
A. Maternal heart rate, 90 beats/min.
B. Fetal heart rate, 100 beats/min
C. Maternal blood pressure, 140/86 mm Hg
D. Maternal temperature,
100.0° FB
Rationale:
A fetal heart rate (FHR) of 100 beats/min may indicate fetal distress (B)
because the average FHR at term is 140 beats/min and the normal range
is 110 to beats/min 160.The others (A, C, and D) are normal findings for a
woman in labor.
The nurse is caring for a client with heart failure who develops respiratory
distress andcoughs up pink frothy sputum. Which action should the nurse
take first?
A. Draw arterial blood gases.
B. Notify the primary health care provider.
C. Position in a high Fowler's position with the legs down.
D. Obtain a chest X-
ray.C
Rationale:
Positioning the patient in a high Fowler's position with dangling feet will
decrease furthervenous return to the left ventricle (C). The other actions
should be performed after the change in position (A, B, and D).
,A client who is prescribed chlorpromazine HCl (Thorazine) for
schizophrenia developsrigidity, a shuffling gait, and tremors. Which action
by the nurse is most important?
A.Administer a dose of benztropine mesylate
(Cogentin) PRN.B.Determine if the client has
increased photosensitivity.
C.Provide comfort measures for sore muscles.
D.Assess the client for visual and auditory
hallucinations.A
Rationale:
Rigidity, shuffling gait, pill-rolling hand movements, tremors, dyskinesia,
and masklikeface are extrapyramidal side effects associated with
Thorazine. It is most important for
,the nurse to administer an anticholinergic such as Cogentin to reverse
these effects (A).The others (B, C, D) may be appropriate interventions but
are not as urgent as (A).
A nurse is interviewing a mother during a well-child visit. Which finding
would alert thenurse to continue further assessment of the infant?
A.Two-month-old who is unable to roll from back to
abdomenB.Ten-month-old who cannot sit without
support
C.Nine-month-old who cries when his mother leaves
the roomD.Eight-month-old who has not yet begun
to speak words
B
Rationale:
As a developmental milestone, infants should sit unsupported by 8 months
(B). The milestone of rolling over is achieved at 5 to 6 months for most
infants (A). Stranger anxiety is common from 7 to 9 months (C). Speaking
a few words is expected at about12 months (D).
Which intervention should be included in the plan of care for a client
admitted to thehospital with ulcerative colitis?
A.Administer stool softeners.
B.Place the client on fluid
restriction.
C.Provide a low-residue diet.
D.Add a milk product to each
meal.C
Rationale:
A low-residue diet (C) will help decrease symptoms of diarrhea, which are
clinical manifestations of ulcerative colitis. (A, B, and D) are contraindicated
, and could worsenthe condition.
The nurse is caring for a client with deep vein thrombosis who is on a
continuous IV heparin infusion. The activated partial prothrombin time
(aPTT) is 120 seconds. Whichaction should the nurse take?
A. Increase the rate of the heparin infusion using a nomogram.
B. Decrease the heparin infusion rate and give vitamin K IM.
C. Continue the heparin infusion at the current prescribed rate.
D. Stop the heparin drip and prepare to administer
protamine sulfate.D
Rationale:
An aPTT more than 100 seconds is a critically high value; therefore, the
heparin shouldbe stopped. The antidote for heparin is protamine sulfate (D).
Increasing the rate wouldincrease the risk for hemorrhage (A). The infusion
should be stopped, and vitamin K is the antidote for warfarin (Coumadin)
(B). Keeping the infusion at the current rate wouldincrease the risk for
hemorrhage (C).
While assessing a client with recurring chest pain, the unit secretary
notifies the nursethat the client's health care provider is on the telephone.
What action should the nurseinstruct the unit secretary to implement?
A. Transfer the call into the room of the client.
B. Instruct the secretary to explain reason for the call.
C. Ask another nurse to take the phone call.
D. Ask the health care provider to see the client on the unit.
C
Rationale:
Another nurse should be asked to take the phone call (C), which allows the
nurse tostay at the bedside to complete the assessment of the client's
chest pain. (A and B)should not be done during an acute change in the
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