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Exam (elaborations)

NCLEX-RN-Questions-Answers-File-1.pdf (1-1674 Q&A)-2023

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A pregnant client is having a nonstress test (NST). It is noted that the fetal heart beat rises 20 bpm, lasting 20 seconds, every time the Question: 3 Which stage of labor lasts from delivery of the baby to delivery of the placenta? A. Second B. Third C. Fourth D. Fifth Answer: B Explanation: (A) This stage is from complete dilatation of the cervix to delivery of the fetus. (B) This is the correct stage for the definition. (C) This stage lasts for about 2 hours after the delivery of the placenta. (D) There is no fifth stage of labor. Question: 4 A client develops complications following a hysterectomy. Blood cultures reveal Pseudomonas aeruginosa. The nurse expects that the physician would order an appropriate antibiotic to treat P. aeruginosa such as: A. Cefoperazone (Cefobid) B. Clindamycin (Cleocin) C. Dicloxacillin (Dycill) D. Erythromycin (Erythrocin) Answer: A Explanation: (A) Cefoperazone is indicated in the treatment of infection withPseudomonas aeruginosa.(B) Clindamycin is not indicated in the treatment of infection withP. aeruginosa.(C) Dicloxacillin is not indicated in the treatment of infection withP. aeruginosa.(D) Erythromycin is not indicated in the treatment of infection withP. aeruginosa. Question: 5 A couple is experiencing difficulties conceiving a baby. The nurse explains basal body temperature (BBT) by instructing the female client to take her temperature: A. Orally in the morning and at bedtime B. Only one time during the day as long as it is always at the same time of day C. Rectally at bedtime D. As soon as she awakens, prior to any activity Answer: D Explanation: (A) Monitoring temperature twice a day predicts the biphasic pattern of ovulation. (B) Prediction of ovulation relies on consistency in taking temperature. (C)Nightly rectal temperatures are more accurate in predicting ovulation. (D) Activity changes the accuracy of basal body temperature and ability to detect the luteinizing hormone surge. Question: 6 A client is having episodes of hyperventilation related to her surgery that is scheduled tomorrow. Appropriate nursing actions to help control hyperventilating include: A. Administering diazepam (Valium) 1015 mg po q4h and q1h prn for hyperventilating episode B. Keeping the temperature in the client’s room at a high level to reduce respiratory stimulation C. Having the client hold her breath or breathe into a paper bag when hyperventilation episodes occur D. Using distraction to help control the client’s hyperventilation episodes Answer: C Explanation: (A) An adult diazepam dosage for treatment of anxiety is 210 mg PO 24 times daily. The order as written would place a client at risk for overdose. (B) A high room temperature could increase hyperventilating episodes by stimulating the respiratory system. (C) Breath holding and breathing into a paper bag may be useful in controlling hyperventilation. Both measures increase CO2 retention. (D) Distraction will not prevent or control hyperventilation caused by anxiety or fear.


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