Nclex Readiness Study Guide Questions With 100% Verified Answers And Rationales Updated 2024

What intervention is essential prior to starting a client on atorvastatin therapy? 1. Assessing for muscle strength 2. Assessing the client's dietary intake 3. Determining if the client is on digoxin therapy 4. Monitoring liver function tests Correct Answer: 4 Rationale Prior to starting therapy with statin medications (eg, rosuvastatin, simvastatin, pravastatin, atorvastatin), the client's liver function tests should be assessed. The drug is metabolized by the hepatic enzyme system and could cause drug-induced hepatitis and increased liver enzymes. Liver function tests should be assessed prior to the start of therapy. Question: 2 The nurse provides discharge instructions to a client at 14 weeks gestation who has received a prophylactic cervical cerclage. Which client statement indicates an understanding of the teaching? 1. "I need to be on bedrest for the duration of my pregnancy." 2. "I will notify my health care provider if I start having low backaches." 3. "Pelvic pressure is to be expected after cerclage placement." 4. "The cerclage will be removed once my baby is at 28 weeks." Correct Answer: 2 Rationale Cervical cerclage is placed to prevent preterm delivery, usually in clients with histories of second-trimester loss or premature birth. A heavy suture is placed transvaginal or trans-abdominally to keep the internal cervical closed. Placement occurs at 12–14 weeks gestation for clients with a history of cervical insufficiency (ie, painless, premature cervical dilation and miscarriage or preterm delivery) or up to 23 weeks gestation if signs of cervical insufficiency (eg, short cervix) are noted. Discharge instructions include activity restriction and recognition of signs of preterm labor (eg, low back aches, contractions, pelvic pressure) and rupture of membranes (Option2). (Option 1) Bed rest is usually recommended for a few days after the procedure. Long-term bed rest is individualized but uncommon and increases the risk for complications (eg, deep vein thrombosis). Pelvic rest (eg, avoiding sexual intercourse) is determined by the health care Provider. (Option 3) Mild abdominal cramping following cerclage placement is common; however, regular contractions, pelvic pressure, and low back aches may indicate preterm labor. (Option 4) The cerclage remains in place until 36–37 weeks gestation. Early removal is indicated by rupture of membranes (to prevent infection) or preterm labor (to prevent damage to the cervix as it dilates). Educational objective: Following cerclage placement, discharge teaching includes recognizing and reporting signs of preterm labor (eg, low back aches, contractions, pelvic pressure) or rupture of membranes and understanding activity restrictions (eg, bed rest for a short time after placement) Question: 3 During the first prenatal assessment, the client reports the last normal menstrual period starting on March 1 and ending on March 5, but also slight spotting on March 23. The client had unprotected intercourse on March 15. Using Naegele's rule, what is the estimated date of birth? 1. December 8 2. December 12 3. December 22 4. December 30 Correct Answer: 1 Rationale Various methods to determine the estimated date of birth (EDB) include the use of Naegele's rule, ultrasound, uterine height measurement (McDonald's measurement), and auscultation of fetal heart rate with a Doppler device. The most accurate dating of pregnancy involves the use of ultrasound around the 16th-18th week of pregnancy. However, Naegele's rule can be used to quickly determine an EDB early in the pregnancy. This calculation uses the date of the first day of the last normal menstrual period (LMP) for the determination of EDB. • EDB = (LMP minus 3 months) + 7 days This client's LMP is March 1, minus 3 months = December 1. Add 7 days to obtain EDB =December 8. Clients who conceive in January, February and most of March will deliver in the current year. Those who conceive after March will deliver in the following year; as a result, a third step is adding 1 to the current year to determine the estimated date of birth. For example, LMP of May 10, 2014 would have an EDB of February 17, 2015. It is important to note that Naegele's rule is based on a client having a menstrual cycle of 28 days. It therefore may not be as accurate if the client has a shorter or longer menstrual cycle. (Option 2) Using the last day of the LMP to calculate EDB provides an inaccurate due date as clients may have varying lengths of menstrual bleeding. (Option 3) Conception occurs around the time of ovulation and is about 14 days from the beginning of the LMP. Eggs are fertile for about 12-24 hours after ovulation with sperm able to remain fertile for 24-72 hours. Implantation of the trophoblast occurs about 7-10 days after fertilization. Using the conception date calculates the gestational age of the embryo approximately 2 weeks later than the true gestational age. (Option 4) Spotting around the time the next menstrual period is due may be considered normal and is probably caused by implantation of the trophoblast into the uterine endometrial lining. This is not considered a problem but using this occurrence to date the pregnancy erroneously delays the EDB by 4 weeks. It is important to calculate EDB from the beginning of the last normal menstrual period. Educational objective: Naegele's rule provides a quick determination of the estimated date of birth (EDB). EDB = (LMP minus 3 months) + 7 days. If the LMP occurs in January, February, or March, the EDB will be in the current year. If the LMP occurs after March, the EDB will be in the next year. Question: 4 A client is prescribed long-term pharmacologic therapy with hydroxychloroquine to treat systemic lupus erythematosus. Which intervention related to the drug's adverse effects should the nurse include in the teaching plan? 1. Have an ophthalmologic examination every 6 months 2. Take the medication on an empty stomach 3. Take vitamin D and calcium supplements 4. Wear a Medic Alert bracelet Correct Answer: 1 Rationale Hydroxychloroquine (Plaquenil) is an antimalarial drug, but it is more commonly prescribed to Reduce fatigue and treat the skin and arthritic (eg, joint inflammation, pain) manifestations of Systemic lupus erythematosus (SLE). Hydroxychloroquine can also help to reduce lupus exacerbations in clients with inactive to mild disease, but several months can pass before its therapeutic effects become apparent. Although rare, serious adverse drug reactions such as retinal toxicity and visual Disturbances can occur with hydroxychloroquine. Therefore, clients are instructed to undergo Regular ophthalmologic examination every 6-12 months (Option 1). (Option 2) Hydroxychloroquine should be taken with food to decrease gastrointestinal upset (A common side effect). (Option 3) Some clients with severe SLE are prescribed long-term corticosteroid (prednisone) Therapy to prevent organ damage and are at risk for adverse reactions, such as accelerated osteoporosis. Osteoporosis is not an adverse reaction of hydroxychloroquine, and vitamin D and calcium supplementation are not required. (Option 4) There are no effects of hydroxychloroquine that would require wearing a Medic Alert bracelet. Educational objective: Hydroxychloroquine (Plaquenil) is used to treat the skin and arthritic manifestations of SLE. Taking the medication with food can help alleviate gastrointestinal upset. Serious adverse drug reactions include retinopathy and visual disturbances; therefore, regular ophthalmologic examination every 6-12 months is required. Question: 5 The nurse is caring for a client diagnosed with Guillain-Barre syndrome (GBS) after a recent gastrointestinal (GI) illness. Monitoring for which of the following is a nursing care priority for this client? 1. Diaphoresis with facial flushing 2. Hypoactive or absent bowel sounds 3. Inability to cough or lift the head 4. Warm, tender, and swollen leg Correct Answer: 3 Rationale GBS is an acute, immune-mediated polyneuropathy that is most often accompanied by ascending muscle weakness and absent deep tendon reflexes. Many clients have a history of antecedent respiratory tract or GI infection. Lower-extremity weakness progresses over hours to days to involve the thorax, arms, and cranial nerves. However, neuromuscular respiratory failure is the most life-threatening complication. Early signs indicating impending respiratory failure include: • Inability to cough • Shallow respirations • Dyspnea and hypoxia • Inability to lift the head or eyebrows Assessing the client's pulmonary function by serial spirometry is also recommended. Measurement of forced vital capacity (FVC) is the gold standard for assessing ventilation; a decline in FVC indicates impending respiratory arrest requiring endotracheal intubation. (Option 1) Severe autonomic dysfunction can present as diaphoresis and facial flushing. (Option 2) The client with GBS is also at risk for paralytic ileus, which is related to either immobility or nerve damage. As a result, the nurse should monitor for the presence of hypoactive/absent bowel sounds. (Option 4) Clients with GBS are at risk of developing deep venous thrombosis due to lack of ambulation and should receive pharmacologic prophylaxis (heparin) and support stockings. Although symptoms in options 1, 2, and 4 represent a progressive illness and are important to communicate to the health care provider promptly, they are not the highest priority compared to impending respiratory failure. Educational objective: Respiratory distress is a potential complication of progressing paralysis in clients with Guillain-Barre syndrome. The nurse should prioritize and monitor for the presence of this complication. Measurement of serial spirometry (FVC) is the gold standard for assessing ventilation. Question: 6 The nurse notes muffled heart tones in a client with a pericardial effusion. How would the nurse assess for a pulses paradoxus? 1. Check for variation in amplitude of QRS complexes on the electrocardiogram strip 2. Compare apical and radial pulses for any deficit 3. Measure the difference between Korotkoff sounds auscultated during expiration and throughout the respiratory cycle. 4. Multiply diastolic blood pressure (DBP) by 2, add systolic blood pressure (SBP), and divide the result by 3; [(DBP x 2) + (SBP)]/3 Correct Answer: 3 Rationale Muffled heart tones in a client with pericardial effusion can indicate the development of cardiac tamponade. This results in the build-up of fluid in the pericardial sac, which leads to compression of the heart. The cardiac output begins to fall as cardiac compression increases, resulting in hypotension. Additional signs and symptoms of tamponade include tachypnea, tachycardia, jugular venous distension, narrowed pulse pressure, and the presence of a pulsus paradoxus. Pulsus paradoxus is defined as an exaggerated fall in systemic BP 10 mm Hg during inspiration. The procedure for measurement of pulsus paradoxus is as follows: 1. Place client in semi-recumbent position 2. Have client breathe normally 3. Determine the SBP using a manual BP cuff 4. Inflate the BP cuff to at least 20 mm Hg above the previously measured SBP 5. Deflate the cuff slowly, noting the first Korotkoff sound during expiration along with the pressure 6. Continue to slowly deflate the cuff until you