Complicated NCLEX Questions

Complicated NCLEX Questions Leave the first rating Students also studied Terms in this set (152) Science MedicineObstetrics Save Psychiatric Mental Health Nursing N...50 terms schwabaccaPreview

Chapter 10: assessment of high risk ...

10 terms amanda_coon5 Preview

Practice NCLEX Q's: Preeclampsia, E...

13 terms maci_mclainPreview High Ri 14 terms brit The client is scheduled to have an amniocentesis for assessment of lung maturity. She seems upset, and says that she doesn't understand how this test could tell if a baby's lungs are mature. What is the best response by the nurse?

• "The amount of bilirubin in amniotic fluid increases as

the lungs mature. We check for yellow colored fluid to assess lung maturity."

• "A chemical called lecithin is made by the fetal lungs

and increases as pregnancy continues. It flows into amniotic fluid, where we can measure it."

• "Please try not to worry about that. Your healthcare

provider knows the procedure well."

• "The fluid changes color as the fetal lungs mature. We

look at the color to determine lung maturity."

• "A chemical called lecithin is made by the fetal lungs and increases as

pregnancy continues. It flows into amniotic fluid, where we can measure it."

Explanation:

To ask a client not to worry or state the healthcare provider knows the procedure well does not provide information to the client. The color of the amniotic fluid is not useful in determining lung maturity. The amount of lecithin increases as the fetal lungs mature. The ratio of lecithin to sphingomyelin is used to assess lung maturity. Bilirubin levels in amniotic fluid do not determine lung maturity.A client who has experienced a spontaneous abortion at

• weeks asks why this happened. What would the nurse

include in a response to address the most common cause of "miscarriage?"

• Excessive activity
• Chromosome abnormalities
• Substance abuse
• Environmental teratogens
• Chromosome abnormalities

Explanation:

The majority of early abortions are related to abnormal chromosomes. The client might fear that she has caused the loss, and should be provided with accurate information. The majority of early abortions are not related to environmental teratogens. The majority of early abortions are not related to excessive activity.The majority of early abortions are not related to substance abuse.

A primigravida is hospitalized at 32 weeks' gestation after a second hemorrhage from a complete placenta previa.The client appears subdued and sad after learning she will remain hospitalized until delivery. She says she is worried about her husband, who will be at home alone much of the time. The nurse interprets the client's response as indicating which psychological state?

• Immaturity
• Denial
• Anxiety
• Ineffective coping
• Anxiety

Explanation:

The client has stated that she is worried, which creates anxiety. The information presented does not represent denial. The information presented does not represent immaturity. There is not enough data to determine whether the client's coping is effective at this time.When caring for a client with pre-eclampsia, which laboratory result should the nurse report to the physician immediately?

• Hemoglobin 11 grams/dL
• Platelets 50,000/mm3
• Creatinine 0.3 mg/dL
• Fasting blood glucose 65 mg/dL
• Platelets 50,000/mm3

Explanation:

Creatinine of 0.3 mg/dl is a normal value during pregnancy. Fasting glucose of 65mg/dl is a normal value during pregnancy. Hemoglobin of 11 grams/dl is a normal value during pregnancy. The normal platelet value is 150,000- 450,000/mm3. The pre-eclamptic client is at risk to develop the potentially fatal HELLP syndrome, with low platelets as one of the defining factors.The nurse determines that which potential problem should be a focus of care for a client undergoing an amniocentesis?

• Inadequate amniotic fluid volume
• Aspiration because of anesthesia
• Anxiety about well-being of fetus
• Dehydration because of NPO status
• Anxiety about well-being of fetus

Explanation:

A client does not have to be NPO prior to amniocentesis. Amniocentesis does not require anesthesia, although a local anesthetic may be used to numb the skin before needle insertion. Most women view invasive antenatal testing with anxiety because of the reason for the test, the impending results, and concern about maternal and fetus complications. Because only 15-20 mL of fluid removed, the client is not at risk for having inadequate amniotic fluid volume.lications.The nurse assesses that which maternal conditions in the third trimester would be a contraindication for conducting a contraction stress test?Select all that apply.

• Marginal abruptio placentae
• Pregnancy at 42 weeks' gestation
• Intrauterine growth restriction
• Diabetes mellitus
• Third trimester bleeding

a, e

Explanation:

Intrauterine growth restriction is an indication for completing a contraction stress test.Diabetes mellitus is an indication for completing a contraction stress test.Post-term pregnancy is an indication for completing a contraction stress test.Contractions elicited during the test could cause increased bleeding if an abruption is present.Contractions elicited during the test could cause increased bleeding if third trimester bleeding is already present.

A client who admits to substance abuse during pregnancy tells the nurse, "I know I am just a really weak person, but I will try to cut down while I'm pregnant." Which response by the nurse would be most therapeutic?

• "I am concerned about you and your baby. What can I

do to help you?"

• "I have heard that before. You need to get serious now,

or your baby will suffer."

• "I don't believe that you are weak at all. You just need

to say no to drugs."

• "That is a very positive plan. Could you tell me more

about feeling like a weak person?"

• "That is a very positive plan. Could you tell me more about feeling like a weak

person?"

Explanation:

"I am concerned about you and your baby. What can I do to help you?" places the emphasis on the nurse instead of the client and is therefore incorrect. "I don't believe that you are weak at all. You just need to say no to drugs." is demeaning and has a negative undertone, and implies the client could do this if she has enough willpower. "I have heard that before. You need to get serious now, or your baby will suffer." is demeaning and negative, although it is true that the fetus could suffer harm from drug use during pregnancy. "That is a very positive plan. Could you tell me more about feeling like a weak person?" acknowledges the client's intent to cut down on substance abuse while seeking additional information about the client's self-concept.A client with type 1 diabetes mellitus gives birth. The postpartum nurse monitors the blood glucose level carefully, expecting that the client's insulin requirements in the first 24 hours after delivery will do which of the following?

• Gradually return to normal.
• Increase slightly.
• Stay the same as before delivery.
• Drop significantly.
• Drop significantly.

Explanation:

The placenta produces human placental lactogen (hPL) and increased amounts of estrogen and progesterone. These hormones interfere with maternal glucose metabolism, and require increased insulin production or supplementation. As soon as the placenta is expelled, these hormone levels fall dramatically, and the mother might require no insulin at all or a very reduced dose in the first 24 hours.A client with a known placenta previa is admitted at 30 weeks gestation with painless vaginal bleeding. The nurse weighs the client's peripads to monitor blood loss. After noting an increased weight of 50 grams, the nurse would document that this equals approximately ___ mL blood loss.50 mL

Explanation:

One mL of blood weighs approximately 1 gram. Thus, if the client's blood loss was equal to 50 grams of weight, it would be the equivalent of 50 mL.A client with pre-eclampsia is receiving magnesium sulfate and oxytocin IV to induce labor at 38 weeks. The nurse determines the magnesium sulfate has been effective after noting which effect on the client?

• Absence of seizures
• Lowered blood pressure
• Onset of sedation
• Stools that are soft
• Absence of seizures

Explanation:

If decreased blood pressure occurs, it is not the intended effect of magnesium sulfate. Magnesium sulfate is a CNS depressant used to prevent seizure activity in the pre-eclamptic client. If sedation occurs, it is not the intended effect of magnesium sulfate. If stools are soft, it is not the intended effect of magnesium sulfate.

A client with heart disease has been prescribed digoxin during her pregnancy. The nurse evaluates that client teaching has been effective when the client makes which statement?

• "I will check my pulse, and not take the medication if it

is less than 60."

• "I will not take antibiotics at the same time as this

medication."

• "I will take this medication with a full glass of water

before breakfast."

• "I will avoid eating foods high in potassium while taking

this medication."

• "I will check my pulse, and not take the medication if it is less than 60."

Explanation:

The client needs adequate potassium for myocardial function. Digoxin is a cardiac glycoside that increases cardiac output by increasing the strength of contraction of the myocardium and slowing the heart rate. A pulse rate lower than 60 is a serious adverse effect of the medication, and the dose should be withheld.Antibiotics are not contraindicated with digoxin. The drug may be given with or without food.Which clinical focus is of highest priority for a client with a missed abortion who has developed disseminated intravascular coagulopathy (DIC)?

• Anxiety about possible death
• Grief regarding loss of fetus
• Risk for bleeding
• Risk for infection
• Risk for bleeding

Explanation:

The client is likely to be experiencing grief related to fetal loss but this is a psychosocial concern that can be addressed once the client is physiologically stable. The client could experience infection but this risk is no greater than for other clients. The client with DIC is at risk for bleeding or hemorrhage which takes priority because of associated physiological consequences such as hypovolemia or shock. The client may or may not be concerned about death, but physiological interventions to stabi-lize the client would take priority.A prenatal client at 14 weeks' gestation reports continuous nausea and vomiting, and a severe headache.The blood pressure is elevated and fundal height is 21 centimeters. Which diagnostic test does the nurse anticipate will be prescribed to confirm a hydatidiform mole?

• Biophysical profile
• Maternal serum alpha-fetoprotein
• Human chorionic gonadotropin
• Sonography
• Sonography

An HIV-positive client in active labor with newly ruptured membranes is being transported to the hospital via ambulance. The nurse anticipates priority administration of which medication to this client?

• Immune globulin
• Zidovudine
• Oxytocin
• Antibiotics
• Zidovudine

Explanation:

An antibiotic could be administered if the membranes were ruptured for an extended time before delivery. There is no indication in the question for immune globulin, which would provide passive immunity against a specific type of infection. There is no indication in the question for oxytocin, which would induce labor. The rate of transmission of HIV to the newborn decreases sharply if the mother is given prophylactic zidovudine orally during pregnancy and by IV during labor.