nclex pass point set 6 study questions
and answers with solutions
The nurse is caring for a client in active labor. The client states, "I feel like I need to push." A
sterile vaginal examination reveals that the client is dilated to 8 cm. What is the nurse's best
response?
"You cannot push yet, you have another 2 cm until you are ready."
"Your cervix is not fully dilated. Let's keep breathing through the pressure."
"Go ahead and push just a little when you feel the urge."
"I will get you some IV pain medication to take the edge off." - ANSWER "Your cervix is not fully
dilated. Let's keep breathing through the pressure."
Explanation:
Pushing (bearing down) before the cervix is completely dilated may cause edema and tissue
damage and may impede fetal descent. This feeling is natural at this stage of labor. Giving the
client IV pain medication at 8 cm can cause fetal respiratory distress. Although it is true that the
client should not push yet, simply stating that fact will not help the client with the pain or
anxiety. Breathing through the pressure is a nonpharmacologic comfort measure.
An adolescent client is using glargine and lispro to manage type 1 diabetes. The nurse reviews
the prescription for sliding scale lispro (see exhibit).
Lispro subcutaneous give units according to sliding scale:Blood glucose: 70 - 150 mg/dL (3.9 to
8.3 mmol/L) = 0 units151-200 mg/dL (8.4 to 11.1 mmol/L) = 1 unit201-250 mg/dL (11.2 to 13.9
mmol/L) = 2 units251-300 mg/dL (14 to 16.7 mmol/L) = 3 units301-350 mg/dL (16.8 to 19.4
mmol/L) = 4 unitsCall for blood glucose > 350 (19.4 mmol/L)In addition give 1 unit for every 15
grams of carbohydrate.The morning blood glucose is 202 mg/dL (11.2 mmol/L) and the client is
going to eat 2 carbohydrate exchanges. The nurse has the client administer how many units of
lispro? Record your answer using a whole number. - ANSWER Correct response:
4
Explanation:
, Each carbohydrate food exchange has 15 grams of carbohydrate. Two units are needed to cover
the current blood glucose, and 2 units are needed to cover the anticipated carbohydrate intake.
A client with Meniere's disease is having an attack of vertigo. Which nursing intervention is the
priority?
Instruct the client to remain in bed.
Use pillows to support the client's head.
Remind the client to ask for assistance when turning.
Assist the client to the restroom every hour. - ANSWER Instruct the client to remain in bed.
Explanation:
The priority intervention is to have the client remain in bed to prevent falls. The other options
are correct; however, client safety is the priority.
A client with acute renal failure has the following laboratory results. Based on these findings,
which of the following should the nurse administer?hemoglobin 9.2 g/dLblood urea nitrogen 22
mg/dLcreatinine 0.7 mg/dLpotassium 4.8 mEq/L
calcium gluconate
potassium chloride
furosemide
erythropoietin - ANSWER erythropoietin
Explanation:
Erythropoietin assists in the production of red blood cells, which are low as evidenced by the
hemoglobin level. All other laboratory values are within normal limits.
A physician orders supplemental oxygen for a client with a respiratory problem. Which oxygen
delivery device should the nurse use to provide the highest possible oxygen concentration?
nasal cannula
venturi mask
and answers with solutions
The nurse is caring for a client in active labor. The client states, "I feel like I need to push." A
sterile vaginal examination reveals that the client is dilated to 8 cm. What is the nurse's best
response?
"You cannot push yet, you have another 2 cm until you are ready."
"Your cervix is not fully dilated. Let's keep breathing through the pressure."
"Go ahead and push just a little when you feel the urge."
"I will get you some IV pain medication to take the edge off." - ANSWER "Your cervix is not fully
dilated. Let's keep breathing through the pressure."
Explanation:
Pushing (bearing down) before the cervix is completely dilated may cause edema and tissue
damage and may impede fetal descent. This feeling is natural at this stage of labor. Giving the
client IV pain medication at 8 cm can cause fetal respiratory distress. Although it is true that the
client should not push yet, simply stating that fact will not help the client with the pain or
anxiety. Breathing through the pressure is a nonpharmacologic comfort measure.
An adolescent client is using glargine and lispro to manage type 1 diabetes. The nurse reviews
the prescription for sliding scale lispro (see exhibit).
Lispro subcutaneous give units according to sliding scale:Blood glucose: 70 - 150 mg/dL (3.9 to
8.3 mmol/L) = 0 units151-200 mg/dL (8.4 to 11.1 mmol/L) = 1 unit201-250 mg/dL (11.2 to 13.9
mmol/L) = 2 units251-300 mg/dL (14 to 16.7 mmol/L) = 3 units301-350 mg/dL (16.8 to 19.4
mmol/L) = 4 unitsCall for blood glucose > 350 (19.4 mmol/L)In addition give 1 unit for every 15
grams of carbohydrate.The morning blood glucose is 202 mg/dL (11.2 mmol/L) and the client is
going to eat 2 carbohydrate exchanges. The nurse has the client administer how many units of
lispro? Record your answer using a whole number. - ANSWER Correct response:
4
Explanation:
, Each carbohydrate food exchange has 15 grams of carbohydrate. Two units are needed to cover
the current blood glucose, and 2 units are needed to cover the anticipated carbohydrate intake.
A client with Meniere's disease is having an attack of vertigo. Which nursing intervention is the
priority?
Instruct the client to remain in bed.
Use pillows to support the client's head.
Remind the client to ask for assistance when turning.
Assist the client to the restroom every hour. - ANSWER Instruct the client to remain in bed.
Explanation:
The priority intervention is to have the client remain in bed to prevent falls. The other options
are correct; however, client safety is the priority.
A client with acute renal failure has the following laboratory results. Based on these findings,
which of the following should the nurse administer?hemoglobin 9.2 g/dLblood urea nitrogen 22
mg/dLcreatinine 0.7 mg/dLpotassium 4.8 mEq/L
calcium gluconate
potassium chloride
furosemide
erythropoietin - ANSWER erythropoietin
Explanation:
Erythropoietin assists in the production of red blood cells, which are low as evidenced by the
hemoglobin level. All other laboratory values are within normal limits.
A physician orders supplemental oxygen for a client with a respiratory problem. Which oxygen
delivery device should the nurse use to provide the highest possible oxygen concentration?
nasal cannula
venturi mask
