Week 9- NCLEX Review Questions
with Rationales
1. The nurse is monitoring a client who is receiving oxytocin to induce
labor. Which assessment findings should cause the nurse to
immediately discontinue the oxytocin infusion? Select all that
apply.
a. Fatigue
b. Drowsiness
c. Uterine hyperstimulation
d. Late decelerations of the fetal heart rate
e. Early decelerations of the fetal heart rate
Rationale:
Oxytocin stimulates uterine contractions and is a
pharmacological method to induce labor. Late
decelerations, a nonreassuring fetal heart rate pattern, is
an ominous sign indicating fetal distress. Oxytocin infusion
must be stopped when any signs of uterine
hyperstimulation, late decelerations, or other adverse
effects occur. Some obstetricians prescribe the
administration of oxytocin in 10-minute pulsed infusions
rather than as a continuous infusion. This pulsed method,
which is more like endogenous secretion of oxytocin, is
reported to be effective for labor induction and requires
significantly less oxytocin use. Drowsiness and fatigue may
be caused by the labor experience. Early decelerations of
the fetal heart rate are a reassuring sign and do not
indicate fetal distress.
2. Methylergonovine is prescribed for a woman to treat postpartum
hemorrhage. Before administration of methylergonovine, what is the
priority assessment?
a. Uterine tone
b. Blood pressure
Rationale:
Methylergonovine, an ergot alkaloid, is used to prevent or
control postpartum hemorrhage by contracting the uterus.
Methylergonovine causes continuous uterine contractions
and may elevate the blood pressure. A priority assessment
before the administration of the medication is to check the
blood pressure. The obstetrician needs to be notified if
hypertension is present. Although options 1, 3, and 4 may
be components of the postpartum assessment, blood
pressure is related specifically to the administration of this
medication.
c. Amount of lochia
d. Deep tendon reflexes
,3. The nurse is preparing to administer exogenous surfactant to a
premature
, infant who has respiratory distress syndrome. The nurse prepares to
administer the medication by which route?
a. Intradermal
b. Intratracheal
Rationale:
Respiratory distress syndrome is a serious lung disorder
caused by immaturity and the inability to produce
surfactant, resulting in hypoxia and acidosis. It is common
in premature infants and may be due to lung immaturity as
a result of surfactant deficiency. The mainstay of treatment
is the administration of exogenous surfactant, which is
administered by the intratracheal route. Options 1, 3, and 4
are not routes of administration for this medication.
c. Subcutaneous
d. Intramuscular
4. Salicylic acid is prescribed for a client with a diagnosis of psoriasis.
The nurse monitors the client, knowing that which finding indicates the
presence of systemic toxicity from this medication?
a. Tinnitus
Rationale:
Salicylic acid is absorbed readily through the skin, and
systemic toxicity (salicylism) can result. Symptoms include
tinnitus, dizziness, hyperpnea, and psychological
disturbances. Constipation and diarrhea are not associated
with salicylism.
b. Diarrhea
c. Constipation
d. Decreased respirations
5. The health education nurse provides instructions to a group of clients
regarding measures that will assist in preventing skin cancer. Which
instructions
with Rationales
1. The nurse is monitoring a client who is receiving oxytocin to induce
labor. Which assessment findings should cause the nurse to
immediately discontinue the oxytocin infusion? Select all that
apply.
a. Fatigue
b. Drowsiness
c. Uterine hyperstimulation
d. Late decelerations of the fetal heart rate
e. Early decelerations of the fetal heart rate
Rationale:
Oxytocin stimulates uterine contractions and is a
pharmacological method to induce labor. Late
decelerations, a nonreassuring fetal heart rate pattern, is
an ominous sign indicating fetal distress. Oxytocin infusion
must be stopped when any signs of uterine
hyperstimulation, late decelerations, or other adverse
effects occur. Some obstetricians prescribe the
administration of oxytocin in 10-minute pulsed infusions
rather than as a continuous infusion. This pulsed method,
which is more like endogenous secretion of oxytocin, is
reported to be effective for labor induction and requires
significantly less oxytocin use. Drowsiness and fatigue may
be caused by the labor experience. Early decelerations of
the fetal heart rate are a reassuring sign and do not
indicate fetal distress.
2. Methylergonovine is prescribed for a woman to treat postpartum
hemorrhage. Before administration of methylergonovine, what is the
priority assessment?
a. Uterine tone
b. Blood pressure
Rationale:
Methylergonovine, an ergot alkaloid, is used to prevent or
control postpartum hemorrhage by contracting the uterus.
Methylergonovine causes continuous uterine contractions
and may elevate the blood pressure. A priority assessment
before the administration of the medication is to check the
blood pressure. The obstetrician needs to be notified if
hypertension is present. Although options 1, 3, and 4 may
be components of the postpartum assessment, blood
pressure is related specifically to the administration of this
medication.
c. Amount of lochia
d. Deep tendon reflexes
,3. The nurse is preparing to administer exogenous surfactant to a
premature
, infant who has respiratory distress syndrome. The nurse prepares to
administer the medication by which route?
a. Intradermal
b. Intratracheal
Rationale:
Respiratory distress syndrome is a serious lung disorder
caused by immaturity and the inability to produce
surfactant, resulting in hypoxia and acidosis. It is common
in premature infants and may be due to lung immaturity as
a result of surfactant deficiency. The mainstay of treatment
is the administration of exogenous surfactant, which is
administered by the intratracheal route. Options 1, 3, and 4
are not routes of administration for this medication.
c. Subcutaneous
d. Intramuscular
4. Salicylic acid is prescribed for a client with a diagnosis of psoriasis.
The nurse monitors the client, knowing that which finding indicates the
presence of systemic toxicity from this medication?
a. Tinnitus
Rationale:
Salicylic acid is absorbed readily through the skin, and
systemic toxicity (salicylism) can result. Symptoms include
tinnitus, dizziness, hyperpnea, and psychological
disturbances. Constipation and diarrhea are not associated
with salicylism.
b. Diarrhea
c. Constipation
d. Decreased respirations
5. The health education nurse provides instructions to a group of clients
regarding measures that will assist in preventing skin cancer. Which
instructions
