NCLEX Study Guide 2024

The charge nurse has received a change of shift report on the following laboring clients. The nurse should give priority for treatment to a A. Client who is 41 weeks pregnant, G2P1, pushing, facial presentation. B. Client who is 39 weeks pregnant, G3P2, amniotomy performed, thin, green fluid. C. Client who is 38 weeks pregnant, G1P0, oxytocin infusing, no cervical dilation in 3 hours. D. Client who is 28 weeks pregnant, G2P1, uterine contractions every 5 minutes, 4 centimeters dilated. - ANS A. Client who is 41 weeks pregnant, G2P1, pushing, facial presentation. explained: for successful vaginal delivery, the fetus should be in a vertex position (I.e., parallel with maternal spine), flexed (I.e., chin to chest), and cephalic (I.e., head down) presentation Facial presentation occurs when the fetal head is fully extended, requiring immediate intervention (e.g., emergent cesarean section). delivering vaginally can cause trauma, spinal cord injuries, fetal distress, and demise. The nurse is screening clients for those at increased risk for developing metabolic acidosis? At highest risk for developing metabolic acidosis is the client who A. Has nausea and vomiting B. Has sepsis and hypotension C. Is taking large doses of thiazide diuretics D. Has decreased oral intake and is dehydrated - ANS B. Has sepsis and hypotension The nurse is caring for a postoperative client who has voided 125 mL since the removal of the indwelling urinary catheter 6 hours ago. Which of the following actions should the nurse take? A. Perform a bladder scan B. Reassess urine output in 1 hour C. Administer 40 mg of furosemide D. Administer a 500 mL IV fluid bolus - ANS A. Perform a bladder scan Explanation: Client is experiencing decreased urinary output (30mL/hr) and requires further assessment to determine the cause. The nurse observes a coworker who is inserting a nasogastric tube. Which of the following actions by the staff member would require the nurse to intervene? A. Uses slight pressure and rotates the tube during insertion B. Advance the nasogastric tube while the client swallows water C. Flushes tube with normal saline after insertion to confirm patency D. Measures tube length from nose, to the earlobe, and then to the xiphoid process - ANS C. Flushes tube with normal saline after insertion to confirm patency Explanation: Nasogastric (NG) tube are flexible tubes placed in the nares down to the stomach. They provide enteral nutrition directly to the stomach or remove gastric contents, decompressing the stomach. NG tube insertion include: 1. Position the client in high-Fowler. 2. Determine the needed tube length 3. Lubricate and inset the tube, aiming towards the back of the throat and down towards the ear. 4. Instruct the client to put chin to chest and repeatedly swallow during in