2026 NCLEX-PN
EXAM PREP 3
500+ NCLEX-Style Questions
(NGN-STYLE QUESTIONS & CASE SCENARIOS)
Answers with detailed Rationale
This Document Description:
• Ideal for practical nursing students preparing for the
NCLEX-PN, strengthening test-taking skills, and boosting
confidence
• Clear, organized format for easy studying
• Printable & digital-friendly
Not affiliated with ATI, VATI or NCLEX. For study purposes only.
,PREVIEW QUESTIONS BELOW
Get the Complete PDF After Purchase
"If you require further clarification or in need of any study
resources, feel free to Message me."
,A nurse is collecting data on a 58 year old client with blurred vision and reduced
visual fields. The nurse finds which clinical manifestation MOST concerning?
A) Difficulty adjusting to dimmed lights
B) Extreme eye pain
C) Gradual loss of peripheral vision
D) Opaque appearance of lens
B, glaucoma is characterized by increased intraocular pressure (IOP) resulting in
compression of the optic nerve. When IOP increases rapidly sudden onset of severe
eye pain can occur.
Gradual loss of vision and difficulty adjusting to lights are not considered emergency
situations. Opaque lenses are characteristics of cataracts which is not a medical
emergency.
The nurse is caring for a patient with diabetes mellitus. The client is alert and
oriented but appears shaky and pale. The client's capillary blood glucose is 50
mg/dL (2.8 mmol/L). Which of the following actions should the nurse take next?
A) Administer 1 mg glucagon IM to the patient
B) Give the patient 4 oz (120 mL of regular soda.
C) Prepare 50 mL of dextrose 50% in water IV push.
D) Repeat the capillary blood glucose level to verify accuracy.
B, hypoglycemia occurs when blood glucose levels fall below 70 mg/dL. Conscious
clients should be given 15 g of a simple carbohydrate (ex. 4 oz regular soda) to quickly
increase the blood glucose level.
IV dextrose and IM glucagon are given to patient who can not digest an oral simple
carbohydrate. The blood glucose should be rechecked 15 minutes after administration
of a simple carbohydrate to check effectiveness.
The nurse is reviewing medical histories with several clients during a community
health screening event. Which of the following client statements indicate a risk
factor for cervical cancer? SATA
A) "I have had four sexual partners during my lifetime."
B) "I have smoked cigarettes for many years."
C) "I never use birth control pills because my partners wore condoms."
,D) "I received treatment for chlamydia when I was younger."
E) "I tested positive for human papillomavirus a few years ago."
A, B, D, E, the most important risk factor for cervical cancer is persistent human
papillomavirus (HPV) infection. Other risks factors for cervical cancer include multiple
sex partners (>1), smoking tobacco, being infected with other STIs (chlamydia). As
these all increase the likelihood of HPV infection.
Condoms help prevent HPV, and not taking oral birth control is associated with a
decreased risk of cervical cancer.
The nurse in the emergency department is caring for a 66 year old client.
GENERAL: The client comes to the ED with fatigue, SOB, dry cough, and
exertional dyspnea for 1 week; the client is homeless; medical history includes
chronic heart failure, uncontrolled hypertension, CAD, and type 2 DM
PULMONARY: VS: RR 22, SpO2 88% on RA; the client is dyspneic but can speak
in full sentences; lung auscultation reveals bilateral crackles; the client reports
smoking 1 pack of cigarettes per day for 35 years; the client was hospitalized with
pneumonia 6 months ago.
CARDIOVASCULAR: VS: T 99 F (37.2 C), P 90, BP 170/100; continuous cardiac
monitor shows sinus rhythm with occasional premature ventricular contractions;
S1, S2, and S3 are heard on auscultation; bilateral lower extremity pitting edema
is noted.
Highlight below the 5 findings that are MOST concerning.
SpO2 88% on RA (hypoxia), lung auscultation reveals bilateral crackles (pulmonary
edema), BP 170/100 (HTN), S3 are heard on auscultation (abnormal heart sounds),
bilateral lower extremity pitting edema (peripheral edema).
Smoking and homelessness require follow-up to ensure the client receives appropriate
resources and support, but they do not require immediate intervention.
Decreased O2, crackles, extra heart tones, HTN, peripheral edema require further
intervention due to concern of fluid overload and impaired gas exchange characteristics
of HF.
The nurse has reviewed the information from the Laboratory Results and
Diagnostic Results, the nurse suspects the client is experiencing acute
decompensated HF. Which of the following findings are consistent with this
condition? SATA
,A) Crackles with auscultation
B) Decreased capillary oxygen saturation
C) Elevated b-type natriuretic peptide
D) left ventricular ejection fraction 30%
E) Lower extremity pitting edema
A, B, C, D, E, Decompensated HF is characterized by pulmonary congestion (crackles,
decreased O2, fluid overload [peripheral edema]). In addition clients will have an
elevated b-type natriuretic peptide and low ejection fraction (<50%).
The nurse should prioritize interventions for acute decompensated heart failure
to reduce the risk of the client developing ____________ and ____________.
Disseminated intravascular coagulation
Bacterial endocarditis
Empyema
Dysrhythmias
Acute kidney injury (AKI)
Dysrhythmias and Acute kidney injury (AKI).
Dysrhythmias are due to structural changes altering the electrical activity of the heart.
AKI is due to hypo-perfusion (decreased perfusion) of vital organs secondary to
decreased cardiac output. Both complications of decompensated HF.
Empyema is pus in the pleural cavity due to bacteria in the lungs, HF can cause pleural
effusions, but empyema is not an expected finding. Bacterial endocarditis can
precipitate HF, but this client shows no signs of infection. DIC is a life threatening
condition from abnormal blood clotting. Caused by sepsis and trauma, HF is not a
common cause.
For each potential intervention, click to specify if the intervention is expected or
not expected for the care of the client.
Potential interventions: Daily weights, IV furosemide, Fluid restriction,
Supplemental oxygen, Antihypertensive medications, nebulized albuterol
breathing treatments.
Expected: Daily weights, IV furosemide, Fluid restriction, Supplemental oxygen,
Antihypertensive medications.
,Not expected:nebulized albuterol breathing treatments
Expected interventions for decompensated HF focus on reducing the cardiac workload
and improving oxygenation.
Nebulized albuterol is a bronchodilator to improve oxygenation in clients with reactive
airway disease (COPD, asthma). They will not improve oxygenation in clients with
pulmonary edema and are NOT expected for treatment of HF.
For the findings below, click to specify if the finding is consistent with the
expected action of the medication carvedilol, enalapril, or furosemide. May
support more than one medication.
Decreases HR
Increased urinary output
Decreases BP
Increases O2 saturation
Carvedilol: Decreases HR and Decreases BP
Enalapril: Decreases BP
Furosemide: Increased urinary output, Decreases BP and Increases O2 saturation
Beta blockers (carvedilol) reduce cardiac workload and decrease myocardial oxygen
demand by DECREASING BP and DECREASING HR
Angiotensin-converting enzyme (ACE) inhibitors (enalapril) reduces circulating
aldosterone, promoting vasodilation resulting in DECREASED BP. Aldosterone retains
Na and water promoting vasoconstriction, we want to use ACE inhibitors to prevent the
release of aldosterone.
Loop diuretics (furosemide) prevent the reabsorption of Na and Cl in the kidneys,
INCREASING URINE OUTPUT and fluid excretion. Decreases in fluid volume will
DECREASE BP and reduce pulmonary edema (INCREASE O2 SATURATION)
Management of HF focuses on reducing cardiac workload and improving cardiac output.
Which of the following findings indicate that the client is improving as expected?
SATA
A) BP 138/70 mm Hg
B) Clear lung sounds
,C) Increased urinary output
D) SpO2 95% on RA
E) Unilateral lower extremity edema
A, B, C, D
Improvement in a client with HF includes improvement of fluid volume status and gas
exchange.
Unilateral lower extremity edema is concerning for DVT and requires immediate follow-
up, as it could lead to a life threatening PE.
The nurse is reinforcing information for a client with COPD. Which statements by
the client indicate the understanding of the pursed lip breathing technique? SATA
A) "I exhale for 2 seconds through pursed lips."
B) "I exhale for 4 seconds through pursed lips."
C) "I inhale for 2 seconds through my mouth."
D) "I inhale for 2 second through my nose, keeping my mouth closed."
E) "I inhale for 4 seconds through my nose, keeping my mouth closed."
B and D
Pursed lip-breathing helps decrease SOB by preventing airway collapse, promoting
CO2 elimination. COPD patients should use this for 5-10 minutes 4 times daily.
Step 1) Relax the neck and shoulders
Step 2) Inhale deeply for 2 seconds through the nose with the mouth closed.
Step 3) Exhale for 4 seconds through pursed lips, as if blowing through a straw. Or
twice as long as inhalation.
The nurse is screening clients for those at risk of developing nephrolithiasis.
Which of the following factors would increase a client's risk of developing
nephrolithiasis. SATA
A) Gout
B) Dehydration
C) Hypokalemia
D) Thrombocytopenia
E) Hyperparathyroidism
A, B, E
Nephrolithiasis (kidney stones) can obstruct the ureters leading to hematuria, flank
,abdominal pain and N/V.
Risk factors for nephrolithiasis include GOUT, frequent UTIs, DEHYDRATION,
HYPERPARATHYROID, and a family history.
Gout increases uric acid in kidneys (uric acid stones). Dehydration increases
concentration of solutes in kidneys. Hyperparathyroidism increases amounts of Ca in
kidneys.
Hypokalemia does not increase the risk for stones, but increases risk for cardiac
dysrhythmias. Thrombocytopenia (low platelets) is not associated with kidney stones,
but increases the risk for bleeding.
The graduate nurse (GN) is caring for a client with a fractured femur in balanced
suspension skeletal traction. Which action by the GN will require precepting
nurse to intervene?
A) Encourages the client to drink plenty of water and choose high-fiber foods
from the diet menu.
B) Lifts the traction weights while the UAP provide a bed bath and linen change.
C) Monitors the incision and pin insertion sites for erythema, drainage, and
malodor.
D) Performs doppler ultrasound pulse checks in the affected leg every hour for
the first 24 hours after surgery.
B, to work effectively skeletal traction must be continuous, therefore weights should not
be lifted or removed, even briefly unless prescribed by the HCP.
The nurse is talking with the client who is entering the second trimester of
pregnancy. Which of the following information should the nurse include? SATA
A) "Anticipate experiencing light fetal movements around 16 to 20 weeks
gestation."
B) "Increase your consumption of iron-rich foods like meat and dried fruit."
C) "Try to gain 3 lb (1.4 kg) each week if your pre pregnancy BMI was normal."
D) "Expect to have an abdominal ultrasound scheduled to check fetal anatomy."
E) "Plan to be screened for gestational diabetes around 24 to 28 weeks
gestation."
A, B, D, E
The second trimester occurs at 14 weeks to 27 weeks and 6 days.Nurse should
reinforce physical changes, potential complications, and routine screening/diagnostic
,test during this time period.
Clients should expect quickening (Clients first perception of fetal movement) at 16-20
weeks, gain approximately 1 lb (0.5 kg) per week if prepregnancy BMI was normal,
consume iron-rich foods, and anticipate screening/diagnostic tests (1-hour glucose
challenge test, fetal anatomy ultrasounds.
The nurse is caring for a 28-year old client in the maternal health clinic. The client
has had right breast pain, fever, chills, fatigue, and increased pain while
breastfeeding her newborn for the past two days. Physical assessment shows
erythema, induration, and tenderness of the right breast. the left breast has no
abnormalities.
For each potential intervention, click to specify if the intervention is indicated or
not indicated for the care of the client.
Administer antibiotics
Increase daily fluid intake
Encourage the client to take NSAIDs for pain
Apply a warm compress to the affected breast
Discontinue breastfeeding until symptoms resolve
Indicated: Administer antibiotics, Increase daily fluid intake, Encourage the client to take
NSAIDs for pain , Apply a warm compress to the affected breast
Not indicated: Discontinue breastfeeding until symptoms resolve
Lactation mastitis is infection and inflammation of breast tissue that may result from
inadequate milk duct drainage or poor breastfeeding technique. Staphylococcus aureus
is the most common causative organism and requires treatment with antibiotics.
For lactational mastitis increase daily fluid intake, relieve pain with NSAIDs or
acetaminophen, apply a warm compress to facilitate emptying, ensure proper
breastfeeding technique.
Discontinue breastfeeding until symptoms resolve is NOT INDICATED. continue
breastfeeding frequently to ensure adequate milk drainage and to relieve milk duct
obstruction. The infant can safely breastfeed from the infected breast because they
already have colonized with maternal microorganisms.
The nurse is monitoring a client who is in active labor with a cervical dilation of 6
sm. Which finding requires intervention by the nurse?
, A) Contraction duration of 95 seconds
B) Contraction frequency of every 3 minutes
C) Contraction intensity of 45 mm Hg
D) Uterine resting tone of 10 mm Hg
A
Uterine contractions in the first stage of labor:
DURATION- 45-80 seconds, should not exceed 90 seconds (reduction of blood flow to
the placenta)
FREQUENCY: 2-5 contractions every 10 minutes, should not occur more frequently
than every 2 minutes (fetal distress from uteroplacental insufficiency)
INTENSITY: Strength at peak time (25-50 mmHg), should not exceed 80 mm Hg (sign
of hypertonicity of the uterus)
RESTING TONE: Tension in uterine muscle between contractions, allows fetal
oxygenation between contractions, average 10 mm Hg, should not exceed 20 mm Hg
The nurse is caring for a client who has been hospitalized for major depressive
disorder. When the nurse reminds the client that breakfast will be served in the
dining room in 20 minutes, the client says, "I'm not hungry and don't feel like
doing anything." Which is the best response by the nurse?
A) "I will help you get ready, then we can walk to the dining room together."
B) "I will have breakfast brought to your room. I know you don't have much
energy right now."
C) "It is okay. You can join us when you are ready. Take your time."
D) You will feel better when you get up and get dressed. You need to eat
something."
A
reduced appetite and low energy level are common in major depressive disorder. Hard
to get out of bed and perform ADLs. Client needs direction and structure with their ADLs
also assistance.
The nurse should assist the client with completing ADLs and with initiating social
interaction with others.
A client with borderline personality disorder says to the nurse, "Your the only one
I trust around here. the others don't know what they are doing and they don't care
about anyone except themselves. I only want to talk with you." What is the
priority nursing action?
A) Assign different staff members to care for the client each day
EXAM PREP 3
500+ NCLEX-Style Questions
(NGN-STYLE QUESTIONS & CASE SCENARIOS)
Answers with detailed Rationale
This Document Description:
• Ideal for practical nursing students preparing for the
NCLEX-PN, strengthening test-taking skills, and boosting
confidence
• Clear, organized format for easy studying
• Printable & digital-friendly
Not affiliated with ATI, VATI or NCLEX. For study purposes only.
,PREVIEW QUESTIONS BELOW
Get the Complete PDF After Purchase
"If you require further clarification or in need of any study
resources, feel free to Message me."
,A nurse is collecting data on a 58 year old client with blurred vision and reduced
visual fields. The nurse finds which clinical manifestation MOST concerning?
A) Difficulty adjusting to dimmed lights
B) Extreme eye pain
C) Gradual loss of peripheral vision
D) Opaque appearance of lens
B, glaucoma is characterized by increased intraocular pressure (IOP) resulting in
compression of the optic nerve. When IOP increases rapidly sudden onset of severe
eye pain can occur.
Gradual loss of vision and difficulty adjusting to lights are not considered emergency
situations. Opaque lenses are characteristics of cataracts which is not a medical
emergency.
The nurse is caring for a patient with diabetes mellitus. The client is alert and
oriented but appears shaky and pale. The client's capillary blood glucose is 50
mg/dL (2.8 mmol/L). Which of the following actions should the nurse take next?
A) Administer 1 mg glucagon IM to the patient
B) Give the patient 4 oz (120 mL of regular soda.
C) Prepare 50 mL of dextrose 50% in water IV push.
D) Repeat the capillary blood glucose level to verify accuracy.
B, hypoglycemia occurs when blood glucose levels fall below 70 mg/dL. Conscious
clients should be given 15 g of a simple carbohydrate (ex. 4 oz regular soda) to quickly
increase the blood glucose level.
IV dextrose and IM glucagon are given to patient who can not digest an oral simple
carbohydrate. The blood glucose should be rechecked 15 minutes after administration
of a simple carbohydrate to check effectiveness.
The nurse is reviewing medical histories with several clients during a community
health screening event. Which of the following client statements indicate a risk
factor for cervical cancer? SATA
A) "I have had four sexual partners during my lifetime."
B) "I have smoked cigarettes for many years."
C) "I never use birth control pills because my partners wore condoms."
,D) "I received treatment for chlamydia when I was younger."
E) "I tested positive for human papillomavirus a few years ago."
A, B, D, E, the most important risk factor for cervical cancer is persistent human
papillomavirus (HPV) infection. Other risks factors for cervical cancer include multiple
sex partners (>1), smoking tobacco, being infected with other STIs (chlamydia). As
these all increase the likelihood of HPV infection.
Condoms help prevent HPV, and not taking oral birth control is associated with a
decreased risk of cervical cancer.
The nurse in the emergency department is caring for a 66 year old client.
GENERAL: The client comes to the ED with fatigue, SOB, dry cough, and
exertional dyspnea for 1 week; the client is homeless; medical history includes
chronic heart failure, uncontrolled hypertension, CAD, and type 2 DM
PULMONARY: VS: RR 22, SpO2 88% on RA; the client is dyspneic but can speak
in full sentences; lung auscultation reveals bilateral crackles; the client reports
smoking 1 pack of cigarettes per day for 35 years; the client was hospitalized with
pneumonia 6 months ago.
CARDIOVASCULAR: VS: T 99 F (37.2 C), P 90, BP 170/100; continuous cardiac
monitor shows sinus rhythm with occasional premature ventricular contractions;
S1, S2, and S3 are heard on auscultation; bilateral lower extremity pitting edema
is noted.
Highlight below the 5 findings that are MOST concerning.
SpO2 88% on RA (hypoxia), lung auscultation reveals bilateral crackles (pulmonary
edema), BP 170/100 (HTN), S3 are heard on auscultation (abnormal heart sounds),
bilateral lower extremity pitting edema (peripheral edema).
Smoking and homelessness require follow-up to ensure the client receives appropriate
resources and support, but they do not require immediate intervention.
Decreased O2, crackles, extra heart tones, HTN, peripheral edema require further
intervention due to concern of fluid overload and impaired gas exchange characteristics
of HF.
The nurse has reviewed the information from the Laboratory Results and
Diagnostic Results, the nurse suspects the client is experiencing acute
decompensated HF. Which of the following findings are consistent with this
condition? SATA
,A) Crackles with auscultation
B) Decreased capillary oxygen saturation
C) Elevated b-type natriuretic peptide
D) left ventricular ejection fraction 30%
E) Lower extremity pitting edema
A, B, C, D, E, Decompensated HF is characterized by pulmonary congestion (crackles,
decreased O2, fluid overload [peripheral edema]). In addition clients will have an
elevated b-type natriuretic peptide and low ejection fraction (<50%).
The nurse should prioritize interventions for acute decompensated heart failure
to reduce the risk of the client developing ____________ and ____________.
Disseminated intravascular coagulation
Bacterial endocarditis
Empyema
Dysrhythmias
Acute kidney injury (AKI)
Dysrhythmias and Acute kidney injury (AKI).
Dysrhythmias are due to structural changes altering the electrical activity of the heart.
AKI is due to hypo-perfusion (decreased perfusion) of vital organs secondary to
decreased cardiac output. Both complications of decompensated HF.
Empyema is pus in the pleural cavity due to bacteria in the lungs, HF can cause pleural
effusions, but empyema is not an expected finding. Bacterial endocarditis can
precipitate HF, but this client shows no signs of infection. DIC is a life threatening
condition from abnormal blood clotting. Caused by sepsis and trauma, HF is not a
common cause.
For each potential intervention, click to specify if the intervention is expected or
not expected for the care of the client.
Potential interventions: Daily weights, IV furosemide, Fluid restriction,
Supplemental oxygen, Antihypertensive medications, nebulized albuterol
breathing treatments.
Expected: Daily weights, IV furosemide, Fluid restriction, Supplemental oxygen,
Antihypertensive medications.
,Not expected:nebulized albuterol breathing treatments
Expected interventions for decompensated HF focus on reducing the cardiac workload
and improving oxygenation.
Nebulized albuterol is a bronchodilator to improve oxygenation in clients with reactive
airway disease (COPD, asthma). They will not improve oxygenation in clients with
pulmonary edema and are NOT expected for treatment of HF.
For the findings below, click to specify if the finding is consistent with the
expected action of the medication carvedilol, enalapril, or furosemide. May
support more than one medication.
Decreases HR
Increased urinary output
Decreases BP
Increases O2 saturation
Carvedilol: Decreases HR and Decreases BP
Enalapril: Decreases BP
Furosemide: Increased urinary output, Decreases BP and Increases O2 saturation
Beta blockers (carvedilol) reduce cardiac workload and decrease myocardial oxygen
demand by DECREASING BP and DECREASING HR
Angiotensin-converting enzyme (ACE) inhibitors (enalapril) reduces circulating
aldosterone, promoting vasodilation resulting in DECREASED BP. Aldosterone retains
Na and water promoting vasoconstriction, we want to use ACE inhibitors to prevent the
release of aldosterone.
Loop diuretics (furosemide) prevent the reabsorption of Na and Cl in the kidneys,
INCREASING URINE OUTPUT and fluid excretion. Decreases in fluid volume will
DECREASE BP and reduce pulmonary edema (INCREASE O2 SATURATION)
Management of HF focuses on reducing cardiac workload and improving cardiac output.
Which of the following findings indicate that the client is improving as expected?
SATA
A) BP 138/70 mm Hg
B) Clear lung sounds
,C) Increased urinary output
D) SpO2 95% on RA
E) Unilateral lower extremity edema
A, B, C, D
Improvement in a client with HF includes improvement of fluid volume status and gas
exchange.
Unilateral lower extremity edema is concerning for DVT and requires immediate follow-
up, as it could lead to a life threatening PE.
The nurse is reinforcing information for a client with COPD. Which statements by
the client indicate the understanding of the pursed lip breathing technique? SATA
A) "I exhale for 2 seconds through pursed lips."
B) "I exhale for 4 seconds through pursed lips."
C) "I inhale for 2 seconds through my mouth."
D) "I inhale for 2 second through my nose, keeping my mouth closed."
E) "I inhale for 4 seconds through my nose, keeping my mouth closed."
B and D
Pursed lip-breathing helps decrease SOB by preventing airway collapse, promoting
CO2 elimination. COPD patients should use this for 5-10 minutes 4 times daily.
Step 1) Relax the neck and shoulders
Step 2) Inhale deeply for 2 seconds through the nose with the mouth closed.
Step 3) Exhale for 4 seconds through pursed lips, as if blowing through a straw. Or
twice as long as inhalation.
The nurse is screening clients for those at risk of developing nephrolithiasis.
Which of the following factors would increase a client's risk of developing
nephrolithiasis. SATA
A) Gout
B) Dehydration
C) Hypokalemia
D) Thrombocytopenia
E) Hyperparathyroidism
A, B, E
Nephrolithiasis (kidney stones) can obstruct the ureters leading to hematuria, flank
,abdominal pain and N/V.
Risk factors for nephrolithiasis include GOUT, frequent UTIs, DEHYDRATION,
HYPERPARATHYROID, and a family history.
Gout increases uric acid in kidneys (uric acid stones). Dehydration increases
concentration of solutes in kidneys. Hyperparathyroidism increases amounts of Ca in
kidneys.
Hypokalemia does not increase the risk for stones, but increases risk for cardiac
dysrhythmias. Thrombocytopenia (low platelets) is not associated with kidney stones,
but increases the risk for bleeding.
The graduate nurse (GN) is caring for a client with a fractured femur in balanced
suspension skeletal traction. Which action by the GN will require precepting
nurse to intervene?
A) Encourages the client to drink plenty of water and choose high-fiber foods
from the diet menu.
B) Lifts the traction weights while the UAP provide a bed bath and linen change.
C) Monitors the incision and pin insertion sites for erythema, drainage, and
malodor.
D) Performs doppler ultrasound pulse checks in the affected leg every hour for
the first 24 hours after surgery.
B, to work effectively skeletal traction must be continuous, therefore weights should not
be lifted or removed, even briefly unless prescribed by the HCP.
The nurse is talking with the client who is entering the second trimester of
pregnancy. Which of the following information should the nurse include? SATA
A) "Anticipate experiencing light fetal movements around 16 to 20 weeks
gestation."
B) "Increase your consumption of iron-rich foods like meat and dried fruit."
C) "Try to gain 3 lb (1.4 kg) each week if your pre pregnancy BMI was normal."
D) "Expect to have an abdominal ultrasound scheduled to check fetal anatomy."
E) "Plan to be screened for gestational diabetes around 24 to 28 weeks
gestation."
A, B, D, E
The second trimester occurs at 14 weeks to 27 weeks and 6 days.Nurse should
reinforce physical changes, potential complications, and routine screening/diagnostic
,test during this time period.
Clients should expect quickening (Clients first perception of fetal movement) at 16-20
weeks, gain approximately 1 lb (0.5 kg) per week if prepregnancy BMI was normal,
consume iron-rich foods, and anticipate screening/diagnostic tests (1-hour glucose
challenge test, fetal anatomy ultrasounds.
The nurse is caring for a 28-year old client in the maternal health clinic. The client
has had right breast pain, fever, chills, fatigue, and increased pain while
breastfeeding her newborn for the past two days. Physical assessment shows
erythema, induration, and tenderness of the right breast. the left breast has no
abnormalities.
For each potential intervention, click to specify if the intervention is indicated or
not indicated for the care of the client.
Administer antibiotics
Increase daily fluid intake
Encourage the client to take NSAIDs for pain
Apply a warm compress to the affected breast
Discontinue breastfeeding until symptoms resolve
Indicated: Administer antibiotics, Increase daily fluid intake, Encourage the client to take
NSAIDs for pain , Apply a warm compress to the affected breast
Not indicated: Discontinue breastfeeding until symptoms resolve
Lactation mastitis is infection and inflammation of breast tissue that may result from
inadequate milk duct drainage or poor breastfeeding technique. Staphylococcus aureus
is the most common causative organism and requires treatment with antibiotics.
For lactational mastitis increase daily fluid intake, relieve pain with NSAIDs or
acetaminophen, apply a warm compress to facilitate emptying, ensure proper
breastfeeding technique.
Discontinue breastfeeding until symptoms resolve is NOT INDICATED. continue
breastfeeding frequently to ensure adequate milk drainage and to relieve milk duct
obstruction. The infant can safely breastfeed from the infected breast because they
already have colonized with maternal microorganisms.
The nurse is monitoring a client who is in active labor with a cervical dilation of 6
sm. Which finding requires intervention by the nurse?
, A) Contraction duration of 95 seconds
B) Contraction frequency of every 3 minutes
C) Contraction intensity of 45 mm Hg
D) Uterine resting tone of 10 mm Hg
A
Uterine contractions in the first stage of labor:
DURATION- 45-80 seconds, should not exceed 90 seconds (reduction of blood flow to
the placenta)
FREQUENCY: 2-5 contractions every 10 minutes, should not occur more frequently
than every 2 minutes (fetal distress from uteroplacental insufficiency)
INTENSITY: Strength at peak time (25-50 mmHg), should not exceed 80 mm Hg (sign
of hypertonicity of the uterus)
RESTING TONE: Tension in uterine muscle between contractions, allows fetal
oxygenation between contractions, average 10 mm Hg, should not exceed 20 mm Hg
The nurse is caring for a client who has been hospitalized for major depressive
disorder. When the nurse reminds the client that breakfast will be served in the
dining room in 20 minutes, the client says, "I'm not hungry and don't feel like
doing anything." Which is the best response by the nurse?
A) "I will help you get ready, then we can walk to the dining room together."
B) "I will have breakfast brought to your room. I know you don't have much
energy right now."
C) "It is okay. You can join us when you are ready. Take your time."
D) You will feel better when you get up and get dressed. You need to eat
something."
A
reduced appetite and low energy level are common in major depressive disorder. Hard
to get out of bed and perform ADLs. Client needs direction and structure with their ADLs
also assistance.
The nurse should assist the client with completing ADLs and with initiating social
interaction with others.
A client with borderline personality disorder says to the nurse, "Your the only one
I trust around here. the others don't know what they are doing and they don't care
about anyone except themselves. I only want to talk with you." What is the
priority nursing action?
A) Assign different staff members to care for the client each day
