NCLEX Questions & Answers Module 7 Test Bank, all answers correct.

NCLEX Questions & Answers Module 7 1. A nurse is preparing to administer vitamin K IM to a newborn. Which of the following actions should the nurse plan to take? 2. The nurse is assessing a 1-year-old infant in the pediatric office. What finding should the nurse report to the physician immediately? 3. A new mother is voicing concern she is breastfeeding her newborn too frequently. How often does the nurse instruct this mother she should expect her newborn to feed? 4. The nurse cautions that children who have unmet hunger needs will likely display which characteristic(s)? (Select all that apply.) 5. Parents of an infant inform the nurse they are planning home preparation of solid foods. What directions should the nurse provide? (Select all that apply.) 6. What contraction duration and interval does the nurse recognize could result in fetal compromise? A woman is 7 cm dilated, and her contractions are 3 minutes apart. When she begins cursing at her birthing coach and the nurse, what does the nurse assess as the most likely explanation for the woman’s change in behavior? 7. The nurse is caring for a woman in the first stage of labor. What will the nurse remind the patient about contractions during this stage of labor? 8. The nurse observes the patient bearing down with contractions and crying out, “The baby is coming!” What is the best nursing intervention? 9. A pregnant woman, gravida 2, para 1, tells the nurse she desires a VBAC (vaginal birth after cesarean section) with this pregnancy. What is the primary concern regarding complications for this patient during labor and birth? 10. assessment immediately following this procedure? 11. A nurse is teaching a childbirth preparation class. The group is discussing individual expression of labor pain. What statement is accurate about a patient’s expression of pain? 12. A nurse instructs a woman’s labor coach to comfort her by firmly pressing on her lower back. What is this technique? 13. A woman who is 6 cm dilated has the urge to push. What will the nurse instruct the woman to do during the contraction? 14. Several hours into labor, a woman complains of dizziness, numbness, and tingling of her hands and mouth. What does the nurse recognize these symptoms signify? 15. What is the most appropriate nursing action to take when a laboring woman hyperventilates? 16.A woman in labor will receive general anesthesia prior to cesarean section. The nurse reminds the patient that food and fluids need to be restricted for several hours prior to delivery. What will this prevent? 17.A woman requests a pudendal block to manage her labor pain. What statement by the woman indicates a need for further explanation about the pudendal block? 18. The nurse is preparing a teaching plan for a woman receiving a subarachnoid block before delivery. What nursing action will be included in this plan to prevent the associated side effect of this type of anesthesia? 19. An 18-year-old primigravida is 4 cm dilated and her contractions are 5 minutes apart. She received little prenatal care and had no childbirth preparation. She is crying loudly and shouting, “Please give me something for the pain. I can’t take the pain!” What is the priority nursing diagnosis? 20. When a pregnant woman arrives at the labor suite, she tells the nurse that she wants to have an epidural for delivery. What is a contraindication to an epidural block? 21. The nurse coaches the primigravida not to bear down until the cervix is completely dilated. What may premature bearing down cause? 22. The physician has ordered Fentanyl (Sublimaze) for a woman in labor and has asked the nurse to provide patient education. What will the nurse include in the educational plan? (Select all that apply.) 23. On examining a woman who gave birth 5 hours ago, the nurse finds that the woman has completely saturated a perineal pad within 15 minutes. The nurse’s first action is to: 24. The laboratory results for a postpartum woman are as follows: blood type, A; Rh status, positive; rubella titer, 1:8 (EIA 0.8); hematocrit, 30%. How would the nurse best interpret these data? 25. A woman gave birth 48 hours ago to a healthy infant girl. She has decided to bottle-feed. During your assessment you notice that both of her breasts are swollen, warm, and tender on palpation. The woman should be advised that this condition can best be treated by: 26. A primiparous woman is to be discharged from the hospital tomorrow with her infant girl. Which behavior indicates a need for further intervention by the nurse before the woman can be discharged? 27. In many hospitals new mothers are routinely presented with gift bags containing samples of infant formula. This practice: 28. In the recovery room, if a woman is asked either to raise her legs (knees extended) off the bed or to flex her knees, place her feet flat on the bed, and raise her buttocks well off the bed, most likely she is being tested to see whether she: 29. A hospital has a number of different perineal pads available for use. A nurse is observed soaking several of them and writing down what she sees. This activity indicates that the nurse is trying to: 30. If a woman is at risk for thrombus and is not ready to ambulate, nurses may intervene by performing a number of interventions. Which intervention should the nurse avoid? 31. As relates to rubella and Rh issues, nurses should be aware that: 33. A recently delivered mother and her baby are at the clinic for a 6-week postpartum checkup. The nurse should be concerned that psychosocial outcomes are not being met if the woman: 34. Which breastfeeding patient is most likely to have severe afterbirth pains and request a narcotic analgesic? 35. Which nursing action is most appropriate to correct a boggy uterus that is displaced above and to the right of the umbilicus? 36. A very anxious young man comes to the clinic believing that he may have HIV infection because of his persistent influenza-like symptoms and his risky sexual behavior. What should the nurse anticipate that a positive blood analysis would show? 37. What indicates that a patient has entered the third stage of HIV infection? 38. A nurse is preparing a teaching plan for a patient with HIV who has been diagnosed with microsporidiosis. Which implementation should be included? 39. Which nursing diagnosis should take priority in the care of an outpatient with AIDS? 40. Which nursing action should be implemented to increase the comfort of a patient with oral hair leukoplakia? 41. Which populations are at the highest risks of contracting HIV? (Select all that apply.) 42. A nurse is designing a teaching plan for a patient with AIDS. What should be included relative to food preparation precautions? (Select all that apply.) 43. Which opportunistic fungal diseases threaten patients with HIV? (Select all that apply.) 44. The nurse instructs a woman taking oral contraceptives to report which possible side effects? (Select all that apply.) 45. A 19-year-old patient has genital warts around her external genitalia and perianal area. She tells the nurse that she has not sought treatment until now because “the warts are so disgusting.” Which nursing diagnosis is most appropriate? 46. A 39-year-old patient with a history of IV drug use is seen at a community clinic. The patient reports difficulty walking, stating “I don’t know where my feet are.” Diagnostic screening reveals positive Venereal Disease Research Laboratory (VDRL) and fluorescent treponemal antibody absorption (FTA-Abs) tests. Based on the patient history, what will the nurse assess (select all that apply)? 47. Which topics will the nurse include when preparing to teach a patient with recurrent genital herpes simplex (select all that apply)? 48. The nurse in the outpatient clinic notes that the following patients have not received the human papillomavirus (HPV) vaccine. Which patients should the nurse plan to teach about benefits of the vaccine (select all that apply)? 49. A 20-year-old woman who is being seen in the family medicine clinic for an annual physical exam reports being sexually active. The nurse will plan to teach the patient about 50. Which assessment data collected by the nurse who is admitting a patient with chest pain suggest that the pain is caused by an acute myocardial infarction (AMI)? 51. After the nurse teaches the patient about the use of carvedilol (Coreg) in preventing anginal episodes, which statement by a patient indicates that the teaching has been effective? 52. A patient who has had chest pain for several hours is admitted with a diagnosis of rule out acute myocardial infarction (AMI). Which laboratory test should the nurse monitor to help determine whether the patient has had an AMI 53. Diltiazem (Cardizem) is ordered for a patient with newly diagnosed Prinzmetal’s (variant) angina. When teaching the patient, the nurse will include the information that diltiazem will 54. The nurse will suspect that the patient with stable angina is experiencing a side effect of the prescribed metoprolol (Lopressor) if the 55. Nadolol (Corgard) is prescribed for a patient with chronic stable angina and left ventricular dysfunction. To determine whether the drug is effective, the nurse will monitor for 56. Heparin is ordered for a patient with a non–ST-segment-elevation myocardial infarction (NSTEMI). What is the purpose of the heparin? 57. When titrating IV nitroglycerin (Tridil) for a patient with a myocardial infarction (MI), which action will the nurse take to evaluate the effectiveness of the medication? 58. A patient is recovering from a myocardial infarction (MI) and develops chest pain on day 3 that increases when taking a deep breath and is relieved by leaning forward. Which action should the nurse take next? 59. Three days after experiencing a myocardial infarction (MI), a patient who is scheduled for discharge asks for assistance with hygiene activities, saying, “I am too nervous to take care of myself.” Based on this information, which nursing diagnosis is appropriate? 60. When caring for a patient who is recovering from a sudden cardiac death (SCD) event and has no evidence of an acute myocardial infarction (AMI), the nurse will anticipate teaching the patient that 61. The nurse is caring for a patient who was admitted to the coronary care unit following an acute myocardial infarction (AMI) and percutaneous coronary intervention the previous day. Teaching for this patient would include 62. A patient who is being admitted to the emergency department with intermittent chest pain gives the following list of medications to the nurse. Which medication has the most immediate implications for the patient’s care? 63. A patient admitted to the coronary care unit (CCU) with an ST-segment-elevation myocardial infarction (STEMI) is restless and anxious. The blood pressure is 86/40 and heart rate is 123. Based on this information, which nursing diagnosis is a priority for the patient? 64. Which information about a patient who has been receiving thrombolytic therapy for an acute myocardial infarction (AMI) is most important for the nurse to communicate to the health care provider? 65. A patient who has chest pain is admitted to the emergency department (ED) and all of the following are ordered. Which one should the nurse arrange to be completed first? 66. When teaching seniors at a community recreation center, which information will the nurse include about ways to prevent fractures? 67. The occupational health nurse will teach the patient whose job involves many hours of typing about the need to. 68. Which discharge instruction will the emergency department nurse include for a patient with a sprained ankle? 69. A 48-year-old patient with a comminuted fracture of the left femur has Buck’s traction in place while waiting for surgery. To assess for pressure areas on the patient’s back and sacral area and to provide skin care, the nurse should. 70. A patient who is to have no weight bearing on the left leg is learning to walk using crutches. Which observation by the nurse indicates that the patient can safely ambulate independently?