NGN NCLEX RN TEST | ALL QUESTIONS AND
CORRECT ANSWERS WITH EXPLANATIONS |
GRADED A+ | VERIFIED ANSWERS | JUST
RELEASED | LATEST VERSION
A nurse is caring for a client at 37 weeks gestation who is undergoing a
contraction stress test. Which fetal strip should the nurse associate with a
negative contraction stress test? ------CORRECT ANSWER---------------A
contraction stress test (CST) evaluates fetal well-being under stress by
identifying uteroplacental insufficiency. Uterine blood flow is decreased
during uterine contractions, which stresses the fetus during labor.
Contractions are stimulated using either oxytocin administration or nipple
stimulation. A fetal tracing is evaluated until 3 uterine contractions, each
lasting 40-60 seconds, are captured within 10 minutes. A negative test has
no late or variable decelerations and is associated with good fetal
outcomes (Option 2). A positive test includes late decelerations with ≥50%
contractions. A suspicious or equivocal test includes variable or prolonged
decelerations or late decelerations with <50% contractions.
intrapartum fetal monitoring ------CORRECT ANSWER---------------Fetal
monitoring gives a clear picture of the FHR, and is the strongest indicator of
how the fetus is tolerating the labor process
Done to evaluate how fetus tolerates labor & to identify possible hypoxic
insult to fetus during labor
Fetal monitoring has two components:
-the woman's contractions
-looking at how the fetus is tolerating labor by identifying changes in the
fetal heart rate.
Fetal monitoring may be internal or external
Fetal monitoring may be continuous or intermittent
,A nurse is reading a client's tuberculin skin test 48 hours after placement
and notes an 11-mm area of induration. The client emigrated from Nigeria 1
year ago and reports no symptoms. Which of the following actions would
be appropriate by the nurse? ------CORRECT ANSWER---------------1. Ask
the client about a history of bacille Calmette-Guérin vaccination
5. Obtain a prescription for a chest x-ray from the health care provider
If a client's tuberculin skin test (TST) is positive, the nurse should:
Ask clients who emigrated from high-prevalence countries if they have
received the bacille Calmette-Guérin (BCG) vaccine. It is commonly
administered to children in high-prevalence countries but causes false-
positive PPD tests (Option 1). Interferon-gamma release assay testing is
preferred in BCG-vaccinated clients because it does not produce false-
positive results.
Obtain a prescription for a chest x-ray to differentiate latent TB from active
disease in asymptomatic clients (Option 5)
PPD test is positive because there is an induration >10 mm and the client
emigrated from a high-prevalence country <5 years ago. There is no
indication to repeat the TST. Airborne precautions NOT droplet
Latent TB infection vs Active TB disease ------CORRECT ANSWER----------
-----
A client arrives in the emergency department with right-sided paralysis and
slurred speech. The nurse understands that the client cannot receive
thrombolytic therapy due to which reason? ------CORRECT ANSWER--------
-------4. Client's symptoms started 12 hours earlier
Thrombolytic therapy (ie, t-PA) is used to dissolve blood clots and restore
perfusion in clients with ischemic stroke. The nurse should assess for
contraindications to t-PA due to the risk for hemorrhage.
,Clients have a 3- to 4.5-hour window from onset of symptoms to receive t-
PA to achieve full effectiveness of thrombolytic therapy
Recent major surgery within the past 14 days is a contraindication because
t-PA dissolves all clots in the body and may therefore disrupt the surgical
site.
-To receive t-PA, clients must have a systolic blood pressure (BP) ≤185
mm Hg and diastolic BP ≤110 mm Hg. In addition, BP should be
maintained at ≤180/105 mm Hg throughout the administration of
thrombolytic therapy and 24 hours thereafter
- Loss of the gag reflex and other major functions would most likely make
the client a candidate for thrombolytics due to proof of deficits from stroke.
Other contraindications include hemorrhagic stroke and stroke or head
trauma within the past 3 months.
A nurse is teaching an inservice regarding prevention of venous
thromboembolism. Which nursing interventions should be included in the
teaching? ------CORRECT ANSWER---------------1. Administer scheduled
anticoagulants
2. Apply sequential compression devices
4. Have clients ambulate regularly as tolerated
5. Instruct clients to point and flex the feet in bed
Venous thromboembolism (VTE) occurs when a thrombus (eg, deep vein
thrombosis) forms and embolizes into the bloodstream (eg, pulmonary
embolism).
VTE prophylaxis should be implemented in all hospitalized clients.
Measures include:
Administration of anticoagulants (eg, enoxaparin), usually prescribed in
clients with a moderate or high risk of VTE (eg, postsurgical) unless
contraindicated (eg, active bleeding) (Option 1)
Application of compression devices or antiembolism stockings to limit
venous stasis (Option 2)
Frequent ambulation, 4-6 times daily as tolerated, to improve circulation
and promote venous return (Option 4)
Foot and leg exercises (eg, extend and flex the feet and knees) to promote
venous return by activating calf muscles (Option 5)
, Elevating the legs while in bed promotes venous return by gravity.
However, the nurse should ensure that any pillows used to elevate the legs
do not place pressure directly behind the knees, as pressure on the
posterior knees compresses leg veins. Clients should also avoid crossing
the legs to prevent pressure on the back of the knees.
A student nurse is accompanying the charge nurse when conducting daily
rounds. Which personal protective measure by the charge nurse does the
student nurse question? ------CORRECT ANSWER---------------3. Wears 2
pairs of gloves when emptying the urinary catheter collection bag of a client
who is HIV positive
The best way for health care workers to protect themselves against
possible HIV transmission is to consistently follow standard (universal)
precautions with all clients, regardless of HIV status. HIV is transmitted
through contact with blood, breast milk, semen, and vaginal secretions. No
extra precautions are needed for routine care of clients that are HIV
positive because the virus is not spread through casual contact, droplets, or
aerosolized particles. Some nurses have the common misconception that
double-gloving reduces the risk of contracting HIV. Appropriate use of a
single pair of clean gloves provides a barrier between the nurse's hands
and the client's blood and body fluids (Option 3).
In compliance with standard precautions, situations in which blood or body
fluids may splash or be sprayed (eg, suctioning, irrigation) require
additional personal protective equipment (eg, face shield, gown) as
necessary.
A client comes to the emergency department with crushing substernal
chest pain. Which of the following interventions should the nurse
anticipate? Select all that apply. ------CORRECT ANSWER---------------1.
Administer IV pain medication
2. Check blood pressure and heart rate
3.Obtain a 12-lead ECG
CORRECT ANSWERS WITH EXPLANATIONS |
GRADED A+ | VERIFIED ANSWERS | JUST
RELEASED | LATEST VERSION
A nurse is caring for a client at 37 weeks gestation who is undergoing a
contraction stress test. Which fetal strip should the nurse associate with a
negative contraction stress test? ------CORRECT ANSWER---------------A
contraction stress test (CST) evaluates fetal well-being under stress by
identifying uteroplacental insufficiency. Uterine blood flow is decreased
during uterine contractions, which stresses the fetus during labor.
Contractions are stimulated using either oxytocin administration or nipple
stimulation. A fetal tracing is evaluated until 3 uterine contractions, each
lasting 40-60 seconds, are captured within 10 minutes. A negative test has
no late or variable decelerations and is associated with good fetal
outcomes (Option 2). A positive test includes late decelerations with ≥50%
contractions. A suspicious or equivocal test includes variable or prolonged
decelerations or late decelerations with <50% contractions.
intrapartum fetal monitoring ------CORRECT ANSWER---------------Fetal
monitoring gives a clear picture of the FHR, and is the strongest indicator of
how the fetus is tolerating the labor process
Done to evaluate how fetus tolerates labor & to identify possible hypoxic
insult to fetus during labor
Fetal monitoring has two components:
-the woman's contractions
-looking at how the fetus is tolerating labor by identifying changes in the
fetal heart rate.
Fetal monitoring may be internal or external
Fetal monitoring may be continuous or intermittent
,A nurse is reading a client's tuberculin skin test 48 hours after placement
and notes an 11-mm area of induration. The client emigrated from Nigeria 1
year ago and reports no symptoms. Which of the following actions would
be appropriate by the nurse? ------CORRECT ANSWER---------------1. Ask
the client about a history of bacille Calmette-Guérin vaccination
5. Obtain a prescription for a chest x-ray from the health care provider
If a client's tuberculin skin test (TST) is positive, the nurse should:
Ask clients who emigrated from high-prevalence countries if they have
received the bacille Calmette-Guérin (BCG) vaccine. It is commonly
administered to children in high-prevalence countries but causes false-
positive PPD tests (Option 1). Interferon-gamma release assay testing is
preferred in BCG-vaccinated clients because it does not produce false-
positive results.
Obtain a prescription for a chest x-ray to differentiate latent TB from active
disease in asymptomatic clients (Option 5)
PPD test is positive because there is an induration >10 mm and the client
emigrated from a high-prevalence country <5 years ago. There is no
indication to repeat the TST. Airborne precautions NOT droplet
Latent TB infection vs Active TB disease ------CORRECT ANSWER----------
-----
A client arrives in the emergency department with right-sided paralysis and
slurred speech. The nurse understands that the client cannot receive
thrombolytic therapy due to which reason? ------CORRECT ANSWER--------
-------4. Client's symptoms started 12 hours earlier
Thrombolytic therapy (ie, t-PA) is used to dissolve blood clots and restore
perfusion in clients with ischemic stroke. The nurse should assess for
contraindications to t-PA due to the risk for hemorrhage.
,Clients have a 3- to 4.5-hour window from onset of symptoms to receive t-
PA to achieve full effectiveness of thrombolytic therapy
Recent major surgery within the past 14 days is a contraindication because
t-PA dissolves all clots in the body and may therefore disrupt the surgical
site.
-To receive t-PA, clients must have a systolic blood pressure (BP) ≤185
mm Hg and diastolic BP ≤110 mm Hg. In addition, BP should be
maintained at ≤180/105 mm Hg throughout the administration of
thrombolytic therapy and 24 hours thereafter
- Loss of the gag reflex and other major functions would most likely make
the client a candidate for thrombolytics due to proof of deficits from stroke.
Other contraindications include hemorrhagic stroke and stroke or head
trauma within the past 3 months.
A nurse is teaching an inservice regarding prevention of venous
thromboembolism. Which nursing interventions should be included in the
teaching? ------CORRECT ANSWER---------------1. Administer scheduled
anticoagulants
2. Apply sequential compression devices
4. Have clients ambulate regularly as tolerated
5. Instruct clients to point and flex the feet in bed
Venous thromboembolism (VTE) occurs when a thrombus (eg, deep vein
thrombosis) forms and embolizes into the bloodstream (eg, pulmonary
embolism).
VTE prophylaxis should be implemented in all hospitalized clients.
Measures include:
Administration of anticoagulants (eg, enoxaparin), usually prescribed in
clients with a moderate or high risk of VTE (eg, postsurgical) unless
contraindicated (eg, active bleeding) (Option 1)
Application of compression devices or antiembolism stockings to limit
venous stasis (Option 2)
Frequent ambulation, 4-6 times daily as tolerated, to improve circulation
and promote venous return (Option 4)
Foot and leg exercises (eg, extend and flex the feet and knees) to promote
venous return by activating calf muscles (Option 5)
, Elevating the legs while in bed promotes venous return by gravity.
However, the nurse should ensure that any pillows used to elevate the legs
do not place pressure directly behind the knees, as pressure on the
posterior knees compresses leg veins. Clients should also avoid crossing
the legs to prevent pressure on the back of the knees.
A student nurse is accompanying the charge nurse when conducting daily
rounds. Which personal protective measure by the charge nurse does the
student nurse question? ------CORRECT ANSWER---------------3. Wears 2
pairs of gloves when emptying the urinary catheter collection bag of a client
who is HIV positive
The best way for health care workers to protect themselves against
possible HIV transmission is to consistently follow standard (universal)
precautions with all clients, regardless of HIV status. HIV is transmitted
through contact with blood, breast milk, semen, and vaginal secretions. No
extra precautions are needed for routine care of clients that are HIV
positive because the virus is not spread through casual contact, droplets, or
aerosolized particles. Some nurses have the common misconception that
double-gloving reduces the risk of contracting HIV. Appropriate use of a
single pair of clean gloves provides a barrier between the nurse's hands
and the client's blood and body fluids (Option 3).
In compliance with standard precautions, situations in which blood or body
fluids may splash or be sprayed (eg, suctioning, irrigation) require
additional personal protective equipment (eg, face shield, gown) as
necessary.
A client comes to the emergency department with crushing substernal
chest pain. Which of the following interventions should the nurse
anticipate? Select all that apply. ------CORRECT ANSWER---------------1.
Administer IV pain medication
2. Check blood pressure and heart rate
3.Obtain a 12-lead ECG
