NCLEX Study Guide 2024
1. The charge nurse has received a change of shift report on the following laboring
clients.
The nurse should give priority for treatment to a
A. Client who is 41 weeks pregnant, G2P1, pushing, facial presentation.
B. Client who is 39 weeks pregnant, G3P2, amniotomy performed, thin, green fluid.
C. Client who is 38 weeks pregnant, G1P0, oxytocin infusing, no cervical dilation in
3 hours.
D. Client who is 28 weeks pregnant, G2P1, uterine contractions every 5 min- utes, 4
centimeters dilated <Ans> A. Client who is 41 weeks pregnant, G2P1, pushing, facial
presentation.
Explanation:
for successful vaginal delivery, the fetus should be in a vertex position (I.e., parallel with
maternal spine), flexed (I.e., chin to chest), and cephalic (I.e., head down) presentation
Facial presentation occurs when the fetal head is fully extended, requiring immedi- ate
intervention (e.g., emergent cesarean section). delivering vaginally can cause trauma, spin
cord injuries, fetal distress, and demise.
2. The nurse is screening clients for those at increased risk for developing metabolic
acidosis?
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,At highest risk for developing metabolic acidosis is the client who
A. Has nausea and vomiting
B. Has sepsis and hypotension
C. Is taking large doses of thiazide diuretics
D. Has decreased oral intake and is dehydrated: B. Has sepsis and hypotension
Explanation:
acid base balance is necessary for homeostasis and is characterized by a blood pH level
between 7.35-7.45. acid base imbalance fare categorized as with respiratory or metabolic
and occur when there is a shift in acidic (e.g., carbon dioxide (CO2) and alkaline (e.g.,
bicarbonate (HCO3) compounds in the body)
metabolic acidosis is caused by an accumulation of acid other than CO2 or when
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123
,bicarbonate is lost through the exertion of the bod fluids. Sepsis deprives cells of
oxygen (hypoxia), forcing them to switch to anaerobic metabolism. This shift
produces lactic acid, leafing to lactic acidosis and metabolic acidosis (I.e., pH <7.37 and high
CO2) as lactic acid
Key takeaway:
a client with sepsis will experience lactic acidosis due to tissue hypoxia.The increase in lactic
acid levels result in metabolic acidosis
3. The nurse is caring for a postoperative client who has voided 125 mL since the
removal of the indwelling urinary catheter 6 hours ago.
Which of the following actions should the nurse take?
A. Perform a bladder scan
B. Reassess urine output in 1 hour
C. Administer 40 mg of furosemide
D. Administer a 500 mL IV fluid bolus: A. Perform a bladder scan
Explanation:
Client is experiencing decreased urinary output (<30mL/hr) and requires further
assessment to determine the cause. It is most appropriate for the nurse to perform a
bladder scan.
A bladder scan is non-invasive bedside procedure that uses an ultrasound probe to
measure the amount of fluid in the bladder. It is indicated if there is suspicion or risk for
urinary retention, such as with the use of anesthesia, indwelling urinary
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, catheters, and anticholinergics. It should be performed within 5-15 minutes of a void to
obtain an accurate post-void-residual volume.
Takeaway:
A bladder scanner is used to assess for a post-void-residual caused by anesthesia, indwellin
urianry catheters, and anticholinergics.
Topic:
Urinary catheterization
4. The nurse observes a coworker who is inserting a nasogastric tube.
Which of the following actions by the staff member would require the nurse to
intervene?
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123
1. The charge nurse has received a change of shift report on the following laboring
clients.
The nurse should give priority for treatment to a
A. Client who is 41 weeks pregnant, G2P1, pushing, facial presentation.
B. Client who is 39 weeks pregnant, G3P2, amniotomy performed, thin, green fluid.
C. Client who is 38 weeks pregnant, G1P0, oxytocin infusing, no cervical dilation in
3 hours.
D. Client who is 28 weeks pregnant, G2P1, uterine contractions every 5 min- utes, 4
centimeters dilated <Ans> A. Client who is 41 weeks pregnant, G2P1, pushing, facial
presentation.
Explanation:
for successful vaginal delivery, the fetus should be in a vertex position (I.e., parallel with
maternal spine), flexed (I.e., chin to chest), and cephalic (I.e., head down) presentation
Facial presentation occurs when the fetal head is fully extended, requiring immedi- ate
intervention (e.g., emergent cesarean section). delivering vaginally can cause trauma, spin
cord injuries, fetal distress, and demise.
2. The nurse is screening clients for those at increased risk for developing metabolic
acidosis?
1/
123
,At highest risk for developing metabolic acidosis is the client who
A. Has nausea and vomiting
B. Has sepsis and hypotension
C. Is taking large doses of thiazide diuretics
D. Has decreased oral intake and is dehydrated: B. Has sepsis and hypotension
Explanation:
acid base balance is necessary for homeostasis and is characterized by a blood pH level
between 7.35-7.45. acid base imbalance fare categorized as with respiratory or metabolic
and occur when there is a shift in acidic (e.g., carbon dioxide (CO2) and alkaline (e.g.,
bicarbonate (HCO3) compounds in the body)
metabolic acidosis is caused by an accumulation of acid other than CO2 or when
2/
123
,bicarbonate is lost through the exertion of the bod fluids. Sepsis deprives cells of
oxygen (hypoxia), forcing them to switch to anaerobic metabolism. This shift
produces lactic acid, leafing to lactic acidosis and metabolic acidosis (I.e., pH <7.37 and high
CO2) as lactic acid
Key takeaway:
a client with sepsis will experience lactic acidosis due to tissue hypoxia.The increase in lactic
acid levels result in metabolic acidosis
3. The nurse is caring for a postoperative client who has voided 125 mL since the
removal of the indwelling urinary catheter 6 hours ago.
Which of the following actions should the nurse take?
A. Perform a bladder scan
B. Reassess urine output in 1 hour
C. Administer 40 mg of furosemide
D. Administer a 500 mL IV fluid bolus: A. Perform a bladder scan
Explanation:
Client is experiencing decreased urinary output (<30mL/hr) and requires further
assessment to determine the cause. It is most appropriate for the nurse to perform a
bladder scan.
A bladder scan is non-invasive bedside procedure that uses an ultrasound probe to
measure the amount of fluid in the bladder. It is indicated if there is suspicion or risk for
urinary retention, such as with the use of anesthesia, indwelling urinary
3/
123
, catheters, and anticholinergics. It should be performed within 5-15 minutes of a void to
obtain an accurate post-void-residual volume.
Takeaway:
A bladder scanner is used to assess for a post-void-residual caused by anesthesia, indwellin
urianry catheters, and anticholinergics.
Topic:
Urinary catheterization
4. The nurse observes a coworker who is inserting a nasogastric tube.
Which of the following actions by the staff member would require the nurse to
intervene?
4/
123
