NUR 4455 Module 3 NCLEX Answers/ Rationale

NUR 4455 Module 3 NCLEX Answers/ Rationale 1. The nurse is assigned to care for a patient who is in early labor. When collecting data from the patient, which should the nurse check first? a. Baseline fetal heart rate b. Intensity of contractions c. Maternal bp d. Freq. of contractions 2. Leopold’s maneuvers will be performed on a pregnant patient. The patient asks the nurse about the procedure. Which information should the nurse provide to the patient about Leopold’s maneuvers? A. The maneuvers measure the height of the maternal fundus B. The maneuvers determine the “lie” and attitude of the fetus C. The maneuvers are systematic method for palpating the fetus through the maternal back D. The maneuvers are a systematic method for palpating the fetus through the maternal abdominal wall 3. The nurse is caring for a patient who is in labor. The nurse rechecks the clients blood pressure and notes that it has dropped. To decrease the incidence of supine hypotension, the nurse should encourage the client to remain in which position? a. Squatting b. Side lying c. Tailor sitting d. Semi-fowlers After a precipitous delivery the nurse note the new mother is passive and only touches her newborn briefly with her fingertips. The nurse should do what to help the women process what has happened a. Encourage the mother to breastfeed soon after birth b. Support the mother in her reaction to the newborn c. Tell the mother that it is important to hold the baby d. Document a complete account of the mothers reaction in the birth record 4. A primigravida’s membrane rupture spontaneously. Which actions should the nurse take first? a. Determine the fetal heart rate b. Prepare for immediate delivery c. Monitor contractions pattern d. Note the amount color and odor of the amniotic fluid 5. After the client vaginally delivers a viable newborn, the nurse sees the umbilical cord lengthen and observes a spurt of blood from the vagina. The nurse recognizes these findings as signs of which condition a. Uterine atony b. Placenta previa c. Abruptio placentae d. Placental separation 6. The nurse is assigned to assist with caring for a client who has been admitted to the labor unit. The client is 9cm dilated and is experiencing precipitous labor. Which is the priority nursing intervention? a. Prepare for oxytocin infusion b. Keep the patient in a side lying position c. Prepare the client for epidural anesthesia d. Encourage the client to start pushing with the contractions The client is admitted to the labor suite complaining of painless vaginal bleeding. The nurse assists with the examination of the client, knowing that which routine labor procedure is contraindicated? e. Leopold’s maneuvers f. A manual pelvic examination g. Hemoglobin and hematocrit evaluation h. External electronic fetal heart rate monitoring 1. A nurse is caring for an older adult client who has type 2 diabetes mellitus and reports difficulty following the diet and remembering to take the prescribed medication. Which of the following actions should the nurse take to promote client adherence to the treatment plan? (select all that apply) a) Ask the dietitian to assist with meal planning. The nurse provides resources to strengthen coping abilities by asking the dietitian to assist the client with meal planning. This will improve client adherence. b) Contact the clients support system. With the client's consent, the nurse can contact members of the clients support system and encourage the client to use this support during times of illness and stress to improve compliance. c) Tell the client he should follow the providers instructions. Telling the client he should follow the providers instructions will not likely improve the client's adherence to the treatment plan. The nurse should determine why the client is not following the treatment plan. d) Encourage the use of daily medication dispenser. The nurse encourages the use of a daily medication dispenser to reduce health risks and improve medication adherence by the client. e) Provide educational materials for home use. The nurse provides educational materials to the client to improve health awareness and reduce health risks after discharge. 2) A nurse in a health care clinic is evaluating the level of wellness for clients using the Illness-Wellness Continuum tool. The nurse should identify which of the following clients as being at the center of the continuum? a) A college student who has influenza b) An older adult who has a new diagnosis of type 2 diabetes mellitus c) A new mother who has a urinary tract infection d) A young male client who has a long history of well-controlled rheumatoid arthritis 3) A nurse is evaluating clients at a health fair for modifiable variables affecting health and wellness. The nurse should identify which of the following variables as modifiable? (select all that apply) a) Smoking on social occasions The nurse identifies smoking as a modifiable variable that a client can change. The nurse should provide the client with educational materials and information on smoking cessation. b) BMI of 28 c) Alopecia d) Trisomy e) History of reflux 4) A nurse is caring for a client who has just told she has breast cancer. The nurse evaluates the client's response. Which of the following statements by the client reflects a negative response to illness? a) “I have no family history of breast cancer.” b) “I need a second opinion. There is no lump.” The nurse should identify this statement as an indication of denial, which is a negative response to illness. Other factors that can influence the response to illness include physical changes, self-perception, and cultural beliefs. c) “I am glad we live in the city near several large hospitals.” d) “I will schedule surgery next week, over the holidays.” 5) A nurse on a medical-surgical unit is caring for a group of clients. The nurse should notify the rapid response team for which of the following clients? a) Client who has an ulceration on the right heel whose blood glucose is 300mg/dL b) Client who reports right calf pain and shortness of breath c) Client who has blood on a pressure dressing in the femoral area following cardiac catherization d) Client who has dark red colorization on the left toes and absent pedal pulse 6) A nurse is caring for a client who has ingested a toxic agent. Which of the following actions should the nurse plan to take? (select all that apply) a) Induce vomiting. b) Instill activated charcoal. c) Perform a gastric lavage with aspiration. d) Administer syrup of ipecac. e) Ensure the client has IV fluids infused. 7) A nurse at a rural community clinic is caring for a client who fell through the ice on a pond, is unresponsive, and is breathing slowly. Which of the following actions should the nurse take? (select all that apply) a) Remove wet clothing b) Maintain normal room temperature c) Apply warm blankets d) Apply a heat lamp e) Ensure the client has warmed IV fluids infused 8) A nurse encounters an unresponsive client during a walk. The client's partner states, “He was pulling weeds in the yard and slumped to the ground.” which of the following techniques should the nurse use to open the client's airway? a) Head-tilt/chin-lift b) Modified jaw thrust c) Hyperextension of the head d) Flexion of the head Henry, N. E., & Holman, H. C. (2017). PN Adult Medical Surgical Nursing (10.0 ed.). Assessment Technologies Institute, LLC. Nadia: 1. A client that attends group sessions at an outpatient mental health clinic has difficulty staying seated because of the constant pain in his lower back. He interrupts the person sitting next to him often when he sighs, whimpers, and cuts him off to talk about the pain. The client begs his daughter to come pick him up because he cannot tolerate being seated for a long time. The nurse observes this as what kind of behavior? a. Opioid intoxication b.Marijuana intoxication c. Somatization d.Hypomania i. RATIONAL: Somatization is when a person has recurring, intense, and multiple complaints about somatic pain. This pain can be real and intense where it interferes with someone’s daily life. It is classified as a mental health disorder. 2. What is an example of an abstract question to ask a client? a. Tell me about what you did last summer? b.What is your favorite beach get away c. How are beach’s and springs similar? d.How is a poodle similar to a greyhound? i. RATIONAL: An abstract question is one that does not include or require the here and now. A person who thinks about dogs in general verses a particular dog is more of an abstractive thinker. 3. According to Maslow’s Hierarchy of needs what is the correct order? a. Self-actualization, esteem needs, belongingness and love need, safety needs, and physiological needs. b.Esteem needs, self-actualization, belongingness and love needs, safety needs, and physiological needs c. Esteem needs, self-actualization, belongingness and love needs, physiological needs, and safety needs 4. What task can a nurse delegate to an assistive personal? a. Feeding a client with aspiration precautions? b.Reinforcing teaching about a gluten free diet c. Reapplying a condom catheter d.Applying a sterile dressing i. RATIONAL: An assistive personal cannot teach, or apply. The AP cannot feed someone who had high precautions and is unstable. If the patient was stable with no precautions the AP would be able to feed but not in this case. The AP can perform non- invasive procedures such as reapplying a condom catheter. Only RN’s can teach and lpn’s can reinforce teaching. 5. What client statement represents an understanding of their newly diagnosed condition of Type 2 Diabetes? a. “My body’s cells are resistant to insulin.” b.“By body is resistant to glucose absorption” c. “My pancreas is not producing insulin as it should.” d.My spleen is not producing insulin as it should.” 6. A nurse is caring for a client who has schizophrenia. The client spends a great deal of time repeating rhyming syllables such as,