NCLEX Questions: Nursing Quiz!

Vaginal bleeding indicates a potential complication of the placenta such as placenta previa. The nurse should instruct the client to notify the provider immediately. Swelling of the ankles is a common occurrence during pregnancy and can be relieved by sitting with the legs elevated. Heartburn occurs during pregnancy due to pressure on the stomach by the enlarging uterus. It can be relieved by eating small meals. Supine hypotension can be experienced by the client who feels lightheaded or faint when lying on her back. The nurse should instruct the client about the side-lying position to remove pressure of the uterus on the vena cava.

N/V during the first trimester might be relieved by eating crackers or plain toast 30-60 min to rising in the morning. Eating during the night can cause heartburn and dose not relieve n/v during the first trimester. Instruct the client to avoid an empty stomach for prolonged periods of time to reduce n/v. Eating a large meal can cause heartburn and does not relieve n/v in the morning.

Hypoactive bowel sounds are a manifestation of peritonitis. The peritoneal inflammation caused by the feces and bacteria released from the perforated appendix results in the development of an ileus, and a decrease in bowel motility. The nurse should recognize that abdominal distention is a manifestation of peritonitis. Tachycardia is a manifestation of peritonitis resulting from infection and fluid shifts within the abdomen which causes hypovolemia. Polyuria occurs with an elevated glucose level and is not a manifestation of peritonitis.

Water does not promote absorption of iron, but drinking water can prevent constipation which is an adverse effect of iron supplements. Milk and calcium interferes with iron absorption. Caffeine in tea and coffee can interfere with iron absorption. The client should consume no more than 200 mg/day because it increases the risk of spontaneous abortion or fetal intrauterine growth restriction. Orange juice contains vitamin C which aids in the absorption of iron.

Nifedipine is an antihypertensive medication that can be administered to women who have gestational hypertension. Pyridoxine (vitamin B6) is a vitamin supplement prescribed for clients who have hyperemesis gravidarum. Ferrous sulfate is a medication used in the treatment of iron deficiency anemia. Calcium gluconate is the antidote for Mg.

Reduced menstrual flow is a common adverse effect of oral contraceptives and usually subsides after a few months of use. Breast tenderness is a common adverse effect of oral contraceptives and usually subsides after a few months of use. Shortness of breath can indicate a pulmonary embolus or myocardial infarction and should be reported to the provider immediately. Headaches are a common adverse effect of oral contraceptives and usually subside after a few months of use.

Administering an enema accelerates bowel motility and increases the risk for perforation of the appendix.

A pain level of 7 on a 0 to 10 scale is considered severe and the nurse should administer an analgesic medication for pain relief.

Administering laxatives accelerates bowel motility and increases the risk for perforation of the appendix

Applying heat to the child's abdomen increases the risk for perforation of the appendix

Iron deficiency anemia is the result of a lack of iron-rich dietary sources, such as meat, chicken, and fish. Ca deficiency can result in poor bone and teeth formation. Maternal obesity can lead to a macrosomic fetus. Neural tube defects are caused by folic acid deficiency. Food sources of folic acid include fresh green leafy vegetables, liver, peanuts, cereals, and whole-grain breads.

A client who experienced a missed abortion would report brownish discharge and no pain. Manifestations of an ectopic pregnancy include unilateral lower quadrant pain with or without bleeding. Use of an IUD is a risk factor associated with this condition. A client who has severe preeclampsia does not have vaginal bleeding and presents with right upper quadrant epigastric pain. A client who has a hydatidiform mole usually has dark brown vaginal bleeding in the 2nd trimester that is not accompanied by abdominal pain.

An IUD will be replaced every 3 to 5 years dependent upon the type of IUD used. Clients do not have to have given birth prior to the insertion of an IUD. It will be necessary for the client to have a negative pregnancy test prior to insertion of the IUD. Fertility will resume immediately following removal of the IUD. The client should check for presence of IUD strings following each menstruation to ensure the device is still present. A change in length of strings should be reported to the provider.

A sodium level of 129 indicates hyponatremia and places the child at increased risk for neurological deficits and seizure activity. The nurse should complete a neurologic assessment and implement seizure precautions in order to maintain the child's safety. In the oliguric phase of AKI the child will have decreased urine output and fluid retention. This can result in water intoxication which predisposes the child to neurologic alterations such as seizures. To ensure accurate evaluation of fluid balance the nurse should plan to weigh the child daily at the same time in the same clothing and using the same scale. A child who has AKI is often hypertensive due to fluid volume excess and the activation of the RAAS. To prevent complications such as hypertensive encephalopathy the nurse should assess the child's blood pressure every 4 to 6 hours. A child who has AKI can develop a fever due to infection. Because AKI is a contraindication to receiving medications that are nephrotoxic, such as NSAIDs, the nurse should use compensatory measures, such as turning a fan on in the room.

The use of quilts or blankets to cover the sleeping infant increases the risk of SIDS due to the potential for suffocation. The nurse should recommend the parents dress the infant warmly and increase the temperature in the home.

Evidence-based practice indicates that supine sleeping is a protective factor against SIDS. Infants who sleep prone are at risk for SIDS due to the potential for oropharyngeal obstruction, ineffective thermal balance, decreased arousal state, and rebreathing of carbon dioxide

A milk allergy either the mother's or the infant's is not a risk factor for SIDS

Evidence-based practice indicates that pacifier use is a protective factor against SIDS. infants should use a pacifier at naptime and bedtime. Parents whose infants are breastfeeding should wait to have the infant use a pacifier until she is breastfeeding successfully

The nurse should place the child who has undergone an allogeneic hematopoietic stem cell transplant in a room with positive-pressure airflow to reduce the risk of disease transmission to the child

The nurse should place a child who has an airborne infection such as measles or varicella into a room with negative-pressure airflow

The nurse should initiate contact precautions for a child who has an illness that can be transmitted by direct contact or contact with the child's items, such as hepatitis A and rotavirus

The nurse should initiate droplet precautions for a child who has pertussis, also known as whooping cough. Pertussis is transmitted through contact with infected large-droplet nuclei that are suspended in the air when the child coughs, sneezes, or talks

Breast tenderness is a common discomfort occurring during the 1st trimester. Urinary frequency too. Epistaxis too. Dysuria is a complication that might occur during pregnancy. The nurse should instruct the client to report this finding to the provider. Epigastric pain is a clinical finding of pregnancy-induced hypertension. The nurse should instruct the client to report this finding to the provider.

A client who has hyperemesis gravidarum will have weight loss and signs of dehydration. A client who has a threatened abortion would be in the 1st trimester and report spotting to moderate bleeding with no enlarged uterus. A client who has a hydatidiform mole exhibits increased fundal height inconsistent with the week of gestation and excessive n/v due to elevated hCG levels. Scant, dark discharge occurs in the 2nd trimester. Preterm labor presents prior to 37 weeks of gestation and is accompanied by pink-stained vaginal discharge and uterine contractions that become more regular.

Ceftriaxone IM or doxycycline PO x 7 days is prescribed for the treatment of gonorrhea. Fluconazole is used to treat candidasis. Metronidazole is used in the treatment of bacterial vaginosis and trichomoniasis. Zidovudine is used to treat HIV/AIDS.

The toddler has begun to develop a sense of body image and boundaries and can be resistant to intrusive assessments such as assessing the mouth or ears, or taking an axillary temperature. Not a finding indicative of physical neglect

Separation anxiety is an expected finding for a toddler. The child of this age can become fearful and exhibit regressive behaviors when left alone with strangers and separated from her parents. Not indicative of physical neglect

The 18 month old toddler has accomplished the gross motor skills of standing and walking and has begun to try to run but falls easily and can have bruises on her knees. No indication of physical neglect

Poor personal hygiene in a toddler is a potential indication of physical neglect. Because toddlers are still dependent on their parents help with hygiene needs, poor personal hygiene indicates a lack of supervision

The child receiving chemotherapy is at risk for anemia due to the chemotherapy effects on the blood forming cells of the bone marrow. The development of anemia is diagnosed through laboratory testing of hemoglobin and hematocrit levels. The nurse should recognize that a Hgb level of 8.5 is below the expected reference range for a 6-year-old child and should be reported to the provider.

It is important for the nurse to consider the child's anticipated length of stay because some client rooms may be larger and thus more comfortable for families during long hospitalizations; however this is not the nurse's priority consideration

It is important to consider the child's treatment schedule when making room assignments because children requiring frequent monitoring and treatments should be assigned to a room close to the nurse's station if possible but this is not the priority consideration

The transmission of infectious diseases is the greatest risk to this child and other children on the unit therefore the child's disease process is the nurse's priority consideration

It is important to consider the child's self care ability when making room assignments because children who require more assistance from nurses or assistive personnel should be assigned a room close to the nurses' station if possible but this is not the nurse's priority consideration

The nurse should administer a tetanus toxoid if it has been more than 5 years since the prior dose

The nurse should apply an antimicrobial ointment to the burned area to prevent infection

The nurse should apply a clean-dry dressing of fine mesh gauze and a light gauze dressing that restricts movement to prevent injury to the wound

Applying ice to the affected area may impair circulation to the area and increase tissue damage

Betamethasone is given to promote lung maturity if delivery is anticipated. Indomethacin is prescribed for the client in preterm labor. Nifedipine is prescribed for the client in preterm labor. Methylergonovine is prescribed for the client experiencing postpartum hemorrhage.

A client experiencing a ruptured ectopic pregnancy has delayed, scant, or irregular menses. TV US would indicate an empty uterus in the client who has ruptured ectopic pregnancy. A serum progesterone level lower than the expected reference range is an indication of ectopic pregnancy. A client's report of severe shoulder pain is a finding associated with a ruptured ectopic pregnancy due to the presence of blood in the abdominal cavity, which irritates the diaphragm and phrenic nerve.

Altered hematocrit is a manifestation of hyperemesis gravidarum due to the hemoconcentration that occurs with dehydration. The presence of ketones in the urine is associated with the breakdown of fats that occurs in a client who has hyperemesis gravidarum. Alanine aminotransferase 20 IU/L. Liver enzymes are elevated in a client who has hyperemesis gravidarum. This finding is within the expected reference range. Decreased serum glucose is anticipated is anticipated in a client who has hyperemesis gradvidarum. This result is within the expected reference range.

Rheumatic fever is an inflammatory disease resulting from an immune response that involves the heart, joints, skin and CNS. There is no indication or benefit to limiting the child's sodium intake.

Rheumatic fever is not contagious to others. Unless requested by parents or child it is not necessary to restrict visitors

The nurse should maintain the child on bed rest as well as limit the child's activity during the acute phase of rheumatic fever to assist with the prevention of cardiac damage

The nurse should administer salicylates to the child who has acute rheumatic fever to decrease fever and discomfort and help to control the inflammatory process

1.8 kg is appropriate for client in 1st trimester. The nurse should be concerned about this client because she has exceeded the expected 3-4 lb weight gain in the first trimester. 6.8 kg (15 lb) weight gain and is in her 2nd trimester. 11.3 kg (25 lb) weight gain and is in her 3rd trimester - within recommended weight gain.

Toddlers who have gastroenteritis and are dehydrated are at increased risk for skin breakdown because of changes in circulation and loss of skin elasticity. The nurse should address another finding first.

Toddlers who have gastroenteritis and are dehydrated may exhibit hypotension because of reduced blood volume. Nurse should address another finding first

Toddlers who have gastroenteritis and are dehydrated may exhibit hyperpyrexia or fever which is caused by the effect of fluid volume depletion on the hypothalamus. Address another finding first

When using the airway, breathing, circulation approach to client care the first finding the nurse should address is the toddler's tachypnea which results when the kidneys are unable to excrete hydrogen ions and produce bicarbonate leading to metabolic acidosis

The child can attend school the next day but he should avoid strenuous activities to prevent bleeding at the insertion site.

The child can resume his regular diet after the procedure.

The child should keep the site clean and dry for at least 3 days to reduce the risk of infection. He should not take a tub bath for 3 days to avoid immersion of the incision in water.

The parent can remove the pressure dressing the day after the procedure and should apply a new adhesive bandage strip daily to the site for at least the next 2 days.

Condoms are used with water-soluble lubricants. A diaphragm should be removed no sooner than 6 hours and no later than 24 hours after intercourse. Acne is reduced when taking oral contraceptives. Contraceptive patches are placed once a week.

The nurse should place the infant in a knee-chest position during a hypercyanotic spell to decrease the return of desaturated venous blood from the legs and to direct more blood into the pulmonary artery by increasing systemic vascular resistance.

The nurse should administer morphine IV to the infant, instead of meperidine, to decrease infundibular spasms that cause a decrease in pulmonary blood flow and right-to-left shunting

The nurse should continue the administration of IV fluids during a hypercyanotic spell to decrease the viscosity of the infant's blood which decreases the risk of CVA

The nurse should apply oxygen at 100% via face mask to assist with dilation of the pulmonary artery and improve oxygen supply to the brain

The acoustic vibration device does not stimulate the uterus. It has no effect on the uterine muscles. It stimulates a sleeping fetus. The acoustic vibration device is activated for 3 seconds on the maternal abdomen over the fetal head to awaken a sleeping fetus.

Fetal position is not a risk factor associated with abruptio placentae. Blunt abdominal trauma is a risk factor for this. Cocaine use is a risk factor too. Maternal age is not. Cigarette smoking is associated risk.

Good sources of calcium for bone and teeth formation include low-oxalate, dark green leafy vegetables, such as kale, artichokes, turnip greens. Deep red or orange vegetables are good sources of vitamins C and A. White breads and rice do not contain high levels of calcium. Meat, poultry, and fish are sources of protein but do not contain high levels of calcium.

AFP is a test to assess for fetal neural tube defects or chromosome disorders. A test of the L/S ratio is done as a part of an amniocentesis to determine fetal lung maturity. Kleihauer-Betke test is used to verify that fetal blood is present during a percutaneous umbilical blood sampling procedure. An indirect Coombs' test detects Rh antibodies in the mother's blood.

The nurse should avoid the use of scissors when performing dressing changes because this can result in accidental cutting of the catheter.

The nurse should flush each lumen of the catheter with a heparin solution daily when not in use

The nurse should use a noncoring angled or straight needle when accessing an implanted port

The nurse should cover the site with a semipermeable transparent dressing to reduce the risk of infection

Applying a cooling blanket can cause shivering and discomfort which increases metabolic requirements and is not effective in reducing the toddler's temperature.

The nurse should recognize that dressing the toddler in minimal clothing will expose the skin to air and maximize heat evaporation from the skin reducing the child's temperature

A tepid bath is lukewarm which can cause discomfort to the toddler and is not effective in reducing fever

Diphenhydramine is an antipruritic rather than an antipyretic medication

Tinnitus is not an adverse effect of implantable progestins. Irregular vaginal bleeding is a potential adverse effect of implantable progestins. Weight gain is a potential adverse effect of implantable progestins. Breast changes are a potential adverse effect of implantable progestins. Gingival hyperplasia is not a potential adverse effect of implantable progestins.

A respiratory rate of less than 12/min, urinary output less than 30 mL/hr, decreased level of consciousness is a sign of Mg tox. The absence of patellar deep-tendon reflexes is a sign of Mg toxicity. Flushing and sweating are adverse effects of Mg but not signs of toxicity.

This is a nontherapeutic response by the nurse and does not acknowledge the client's concerns. Feelings of ambivalence about pregnancy are normal during the first trimester. The others are nontherapeutic.

TORCH infx are flu-like in presentation, such as joint pain, malaise, rash, and tender lymph nodes.

Weight gain can occur when taking this medication. This med does not provide protection against STIs. Clients should take calcium and vitamin D to prevent loss of bone density, which can occur when taking this medication. Antibiotics are not contraindicated. This medication can cause irregular vaginal bleeding.

An episiotomy should be avoided for a client who is HIV-positive due to the risk of maternal blood exposure. Oxytocin infusion is not contraindicated for this client. The use of forceps during delivery should be avoided due to risk of fetal bleeding. Cesarean birth is not contraindicated for this client. Internal fetal monitoring should be avoided due to the risk of bleeding.

The nurse should plan to administer pancreatic enzymes within 30 minutes of meals and snacks.

A child who has CF and develops steatorrhea or fatty stools needs to increase the intake of pancreatic enzymes.

The nurse should encourage fluid intake, rather than restrict it, to prevent dehydration caused by the loss of sodium and chloride through perspiration.

A child who has CF is unable to properly digest fats due to fibrosis of the pancreas and limited secretion of pancreatic enzymes.

The nurse should increase the child's fat intake to equal 40% of total caloric intake.

Fetal weight and fetal position are not one of the variables included in the BPP. Fetal breathing movements, fetal tone, and amniotic fluid volume are included in the BPP.

Erythromycin is administered to the infant immediately following delivery to prevent Neisseria gonorrhoeae. Erythromycin is administered to the infant immediately following delivery to prevent chlamydia. Retrovir is prescribed to a client in labor who is HIV-positive. Penicillin G or ampicillin may be prescribed to treat positive GBS. A TORCH infection can be treated during pregnancy depending upon the infection.

Lifting may be done by using the legs rather than the back. Kegel exercises are done to strengthen the perineal muscles and do not relieve backache. The pelvic rock or tilt exercise stretches the muscles of the lower back and helps relieve lower back pain. The use of proper body mechanics prevents back injury due to the incorrect use of muscles when lifting. Avoiding constrictive clothing helps prevent UTIs, vaginal infx, varicosities, and edema of the lower extremities.

Obesity, multifetal pregnancy, and migraine headache are risk factors for hyperemesis gravidarum. Maternal age less than 30 is a risk factor for hyperemesis gravidarum. Oligohydramnios is not a risk factor for hyperemesis gravidarum.

2.2 lb/1 kg = pt weight in lb/X kg
2.2 lb/1 kg = 75 lb/ X kg
X = 34

1.2 mg x 34 kg = 40