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NCLEX EXAM PREVIEW

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sum Category: Postpartum

The nurse reviews the care needs for a group of postpartum clients. Which client does the nurse identify as being most at risk for developing postpartum hemorrhage?

• Client who delivered a 9 lb, 8 oz (4.3 kg) newborn.
• Client with an episiotomy.
• Client with engorged breasts.
• Client requesting assistance with fundal massage.
• Client who delivered a 9 lb, 8 oz (4.3 kg) newborn. (Correct answer)

Delivery of a large birthweight infant (greater than 9 lb [4.1 kg]) leads to increased uterine stretching, which can cause uterine fatigue and poor tone.

• Client with an episiotomy.

An episiotomy can cause discomfort but is not a risk factor for postpartum hemorrhage.

• Client with engorged breasts.

Engorged breasts are filled with milk. This is not a risk factor for a postpartum hemorrhage.

• Client requesting assistance with fundal massage.

Fundal massage expels blood clots and helps uterine blood vessels to contract. This is not a risk factor for postpartum hemorrhage.

Category: Renal

The nurse provides care for a client diagnosed with prerenal acute kidney injury. Which action will the nurse perform first?

• Assess for history of prostate enlargement.
• Insert an indwelling urinary catheter.
• Monitor the client's daily weights.
• Assess the client's blood pressure.
• Assess for history of prostate enlargement.

Prostate enlargement with urinary obstruction may cause postrenal AKI, rather than prerenal AKI. The client's history will not assist the nurse to determine the client's immediate stability.

• Insert an indwelling urinary catheter.

Although monitoring the client's urinary output is a priority, there is no indication that a urinary catheter is required for this client.Monitor the client's daily weights.

• Monitoring the client's daily weight is appropriate, but the nurse should first assess the client's blood pressure to ensure that the client is

stable in the "here and now."

• Assess the client's blood pressure. (Correct answer)

Decreased cardiac output and hypovolemia are causes of prerenal acute kidney injury (AKI). The nurse should ensure that the client's blood pressure is adequate to ensure kidney perfusion.The nurse in the outpatient clinic has four phone messages. Which message does the nurse return first?

• An older adult client undergoing bowel prep and reporting watery diarrhea.
• A client with a newborn and experiencing breast engorgement.
• A client who had a cataract extraction 3 days ago and reported nausea.
• A client diagnosed with a C6 spinal cord injury and reporting a headache.
• An older adult client undergoing bowel prep and reporting watery diarrhea.This client requires teaching, but this client is experiencing

expected results from the bowel prep.

• client with a newborn and experiencing breast engorgement.The client is experiencing an anticipated issue that is not life-threatening. Though

further assessment and teaching are required, the client is stable.

• A client who had a cataract extraction 3 days ago and reported nausea.Vomiting increases intraocular pressure, which may affect the suture

line and pose a risk of physical harm to the client. However, there is another client who is more unstable and experiencing an actual (real) problem that is potentially life-threatening.

• A client diagnosed with a C6 spinal cord injury and reporting a headache. (Correct Answer)

A severe headache is indicative of autonomic dysreflexia in the client who has sustained a high-level spinal cord injury. Autonomic dysreflexia is associated with a dangerously high blood pressure, and, if untreated, can result in intracranial bleeding and death. This client is the most unstable and is experiencing a potentially life-threatening issue that needs to be addressed immediately by the nurse.

The home care nurse visits a client diagnosed with acquired immune deficiency syndrome (AIDS). The nurse instructs the client's caregiver about how to prevent infection. Which is the most important instruction the nurse will give to the caregiver?

• "Cover your nose and mouth when you sneeze or cough."
• "Get rid of all pets in the home."
• "Wash your hands frequently."
• "Wash the client's dishes separately."
• "Cover your nose and mouth when you sneeze or cough."This is an appropriate action because the client is susceptible to illness. However,

the priority is to ensure that the caregiver is performing hand hygiene, as this is the largest source of contamination.

• "Get rid of all pets in the home."This is not necessary. However, the client should not touch litter boxes, feces, bird droppings, or water in the

fish tank. The nurse should encourage the client to wash hands with soap and water after handling the family pet.

• "Wash your hands frequently." (Correct Answer)Hand hygiene is the single best way to kill germs. The caregiver should wash hands after

going to the bathroom and before and after fixing food. The caregiver should also wash hands before and after caring for the client.

• "Wash the client's dishes separately."This is not necessary. All dishes may be washed together. Terms (4)

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