NCLEX NGN Pre-Test Questions and Answers With Rationale

NCLEX NGN Pre-Test Questions and Answers With Rationale A client with a diagnosis of preeclampsia suddenly begins to exhibit seizure activity. Which is the first action on the part of the nurse? a. Calling the physician b. Inserting an oral airway c. Turning the client on her side d. Noting the time of the seizure [Correct Ans: -C A nurse is preparing to administer an injection of vitamin K to a newborn. At which site would the nurse select to administer the medication? [Correct Ans: -3 The preferred injection site for the administration of vitamin K in the newborn is the lateral aspect of the middle third of the vastus lateralis muscle (the newborn's thigh). This muscle is the preferred injection site because it is free of major blood vessels and nerves and is large enough to absorb the medication A nurse performs a bedside glucose test on a newborn infant whose mother has diabetes mellitus and obtains a reading of (2.164 mmol/L)35 mg/dL. The nurse would take which action first? Ask the mother to breastfeed the newborn Bottle-feed the newborn with diluted glucose Start an intravenous line for the administration of glucose Ask the laboratory to perform a blood glucose test immediately [Correct Ans: -D Normal newborn levels are 40 mg/dL or greater. Glucose levels of less than (2.22-2.298 mmol/L))40 to 45 mg/dL measured with bedside glucose screening should be reported and verified in the laboratory. Although feeding is an intervention, the result of a bedside glucose must be verified by the laboratory. Some infants need IV glucose to maintain glucose balance and prevent damage to the brain. A pregnant woman is being admitted to the maternity unit. The woman tells the nurse that she felt a large gush of fluid from her vagina on the way to the hospital. The nurse detects a fetal heart rate of 90 beats/min. On physical examination, the nurse finds that the umbilical cord is protruding from the vagina. Which actions should the nurse perform? Select all that apply. Placing the woman in knee-chest position Administering oxygen at 2 to 4 L/min by nasal cannula Administering terbutaline to stop contractions With two gloved fingers, exerting upward pressure, into the vagina, on the presenting part Wrapping the cord loosely in a sterile towel saturated with warm sterile normal saline solution [Correct Ans: -A, C, D Oxygen should be administered at 8-10 L/min via face mask A nurse provides information to the mother of a child with diarrhea about signs and symptoms that indicate the need to call the primary health care provider. Which statement by the mother indicates the need for further instruction? "I'll call the doctor if she gets dizzy and acts sick." "I'll call the doctor if she has severe stomach cramps." "I'll call the doctor if her temperature is 102°F (38.9°C) or higher." "I'll call the physician if she goes longer than 6 hours without urinating." [Correct Ans: -C Call doctor at temperature above 100. A nurse reviewing the medical history of an infant experiencing gastroesophageal reflux (GER) would expect to note documentation of which other issue? Refusal to suck Frequent diarrhea Recurrent otitis media Inability to pass stools [Correct Ans: -C Vomiting or spitting up after a meal, hiccupping, and recurrent otitis media resulting from pooling of secretions in the nasopharynx during sleep are characteristics of all types of GER