NCLEX Final Exam Question & Answers with Complete Solution 2023 Graded A

OB A nurse is caring for a client who is at 36 weeks of gestation and who has a suspected placenta previa. Which of the following findings support this diagnosis? Painless red vaginal bleeding Placenta Previa is a condition of pregnancy when the placenta implants in the lower part of the uterus, partly or completely obstructing the cervical os (outlet to the vagina). Bright red, painless vaginal bleeding occurs in the second and third trimester. A nurse in labor and delivery is caring for a client. Following delivery of the placenta, the nurse examines the umbilical cord. Which of the following vessels should the nurse expect to observe in the umbilical cord? Two arteries and one vein The vein carries the oxygenated, nutrient rich blood from the placenta to the fetus, and the two arteries returned the blood to the placenta. A nurse is caring for a client who is in premature labor and is receiving terbutaline. The nurse should monitor the client for which of the following adverse effects that should be reported to the provider? Dyspnea The presence of dyspnea is a manifestation of pulmonary edema, which is a potentially life- threatening complication of terbutaline. This finding should be reported to the provider immediately. A nurse is providing teaching about nutrition to a client at her first prenatal visit. Which of the following statements by the nurse should be included in the teaching? You will need to double your intake of iron during pregnancy. During pregnancy, the need for iron increases to allow transfer of the appropriate amounts to the fetus and to support expansion of the client’s RBC volume. A nurse is admitting a client who is at 38 weeks of gestation and is in the first stage of labor. Which of the following assessment findings should the nurse report to the provider first? Continuous contractions lasting 2 minutes long. A uterus contracting for more than 90 seconds is a sign of tetany and could lead to uterine rupture, which is the greatest risk to the client at this time. Med-Surg A nurse is admitting a client who has acute pancreatitis. Which of the following provider prescriptions should the nurse anticipate? Pantoprazole Anticipate a prescription for a proton pump inhibitor to decrease gastric motility acid production, which ultimately decrease pancreatic secretions. A nurse is assessing a client who is receiving one unit of packed RBC’s to treat intraoperative blood loss. The client reports chills and back pain, and the client’s blood pressure is 80/64 mm Hg. Which of the following actions should the nurse take first? Stop the infusion of blood. The client is experiencing an acute intravascular hemolytic transfusion reaction. The greatest risk to the client is injury from receiving additional blood, therefore the first action the nurse should take is to stop the infusion of blood. A nurse is caring for a client who has a new diagnosis of myasthenia gravis. For which of the following manifestations should the nurse monitor? Weakness Generalized weakness of the diaphragmatic and intercostal muscles may produce respiratory distress or predispose the client to respiratory infections. A nurse is caring for a client who is being admitted for an acute exacerbation of ulcerative colitis. Which of the following actions should the nurse take first? Review the client’s electrolytes The greatest risk to this client is injury from impaired function of cardiac or respiratory muscles; therefore the first action the nurse should take is to review the client’s electrolyte values. The client might have low sodium, potassium and chloride from frequent diarrhea. A nurse is observing the closed drainage system of a client who is 24 hr pst thoracotomy. The nurse notes slow, steady bubbling in the suction control of the chamber. Which of the following actions should the nurse take? Continue to monitor the client’s respiratory status Slow, steady bubbling in the suction control chamber is an expected finding. Therefore, the nurse should continue to monitor the client’s respiratory status. A nurse is caring for four hospitalized clients. Which of the following clients should the nurse identify as being at risk for fluid volume deficit? The client who has gastroenteritis and is febrile This client has 2 risk factors for the development of fluid volume deficit or dehydration. Pharm A nurse is caring for four clients for whom she has to administer oral medications in the morning. The nurse should administer which of the following medications before breakfast? Alendronate The client must take alendronate first thing in the morning on an empty stomach and wait at least 30 min before eating, drinking or taking other meds. A nurse is assessing a client who is taking levothyroxine. The nurse should recognize that which of the following findings is a manifestation of levothyroxine overdose? Insomnia Levothyroxine overdose will result in manifestations of hyperthyroidism, which can include insomnia, tachycardia, and hyperthermia.