NCLEX questions, answers, rationals

NCLEX questions, answers, rationals ScienceMedicineNursing Maggie_Persinger Save PEARSON NCLEX-RN Questions & R...199 terms Candice_Haygood Preview NCLEX Question Bank with Rational...77 terms Haley_Malzac Preview 75 Free NCLEX Questions - c/o Brilli...75 terms carey47Preview NCLEX 110 term kan Which of the following are agencies that focus on global health and development? Select all that apply.

• World Health Organization
• United Nations
• National Institutes of Health
• American Nurses Association
• World Health Organization
• United Nations

Rationale: The NIH and ANA deal with local health issues within the United States while the WHO and United Nations deal with global health.The number of deaths of infants younger than 28 days of age per 1000 live births is termed the:

• infant death rate.
• neonatal birth rate.
• neonatal morbidity rate.
• neonatal mortality rate.
• neonatal mortality rate.

Rationale: Neonatal mortality rate is defined as the number of deaths of infants under age 1 year per 1000 live births. Birth rate and neonatal birth rate refer to the number of births per 1000 population in a year. Neonatal morbidity rate refers to illness.

Which nursing action is the priority when a patient arrives at the clinic?

• Prepare a plan of care.
• Select the appropriate nursing diagnoses.
• Administer medications as ordered.
• Determine and document history and vital signs.
• Determine and document history and vital signs.

Rationale: Assessment is the first step of the nursing process and includes the collection of subjective and objective patient data. Diagnosis is the second step of the nursing process. Preparing a plan of care refers to the fourth step: planning. Administering medications relates to implementation, which is the fifth step of the nursing process.Which of the following organizations sets standards of practice for nursing?

• American Medical Association (AMA)
• American Nurses Association (ANA)
• Utilization review committee
• American Academy of Pediatrics (AAP)
• American Nurses Association (ANA)

Rationale:The ANA develops standards of practice. The AMA is a medical association that is geared toward physicians. Utilization review committee reviews appropriateness of health care services and guidelines for physicians for treatment of illness, controlling management of care to achieve cost containment. The AAP is made up of pediatricians and establishes positions of leadership in setting standards of care for children.

The nurse is providing evidence-based care when he or she:

• adheres to hospital procedures book guidelines.
• carries out protocols learned in nursing school.
• carries out the practice requested by the charge nurse or health care provider.
• knows that the practice has been published in a professional journal or text.
• knows that the practice has been published in a professional journal or text.

Rationale: Evidence-based practice starts when the nurse uses the best evidence obtained from current, valid, published research. When the nurse combines that information with his or her critical thinking process, experiences, and patients' needs, it is then possible to plan safe, effective nursing care for the patient. The other answer options are not accurate.which source would the nurse use to determine whether a specific nursing activity is within the scope of practice on an LPN/LVN?

1.Doctor's prescription record

• Nursing procedure manual
• Head nurse or nurse manager
• The nurse practice act
• The nurse practice act

Rationale: Specific activities are listed by the state nurse practice act and nurses must practice within the limitations of the nurse practice act for their state. The other answer options are not sources that determine scope of practice.

Nursing organizations that suggest standards of care in maternal-child nursing are:

• AWHONN
• ANA
• QSEN
• AAP
• c and d
• a and b
• b and c
• b and d
• c and d
• QSEN
• AAP

Rationale: QSEN has to do with delivering quality care; American Academy of Pediatrics (AAP) is managed by physicians who set standards for pediatric care delivered by physicians. AWHONN and ANA set standards for nursing care.

Spermatozoa are produced in the:

• vas deferens.
• seminiferous tubules.
• prostate gland.
• Leydig cells.
• seminiferous tubules.

Rationale: Sperm are made in the convoluted seminiferous tubules of the testes. The other answer options are not correct because sperm are produced only in the testes.A woman can keep a diary of her menstrual cycles to help determine her fertile period. She understands that after ovulation she will remain

fertile for:

• 2 hours.
• 24 hours.
• 3 to 5 days.
• 7 to 14 days.
• 24 hours.

Rationale: The egg lives for only 24 hours after ovulation; therefore it is viable for fertilization only for 24 hours.

Which data indicate that a woman may have pelvic dimensions that would be inadequate for a normal vaginal delivery? A woman with a(n):

• anthropoid-shaped pelvis with a history of pelvic inflammatory disease
• gynecoid_shaped pelvis with a history of rickets
• anthropoid-shaped pelvis that previously delivered a 9-lb infant
• gynecoid-shaped pelvis with a history of poor nutrition
• gynecoid_shaped pelvis with a history of rickets

Rationale: Although the gynecoid-shaped pelvis is considered most favorable for a vaginal delivery, a woman with a history of rickets (a disease in which normal bone formation is disturbed when bone fails to mineralize and becomes soft and distorted) would be the most likely of the choices for inadequate normal vaginal delivery. An anthropoid-shaped pelvis with a history of PID, although not most favorable, allows for possible vaginal delivery, and history of PID might interfere with conception but not delivery. Previous delivery of a large infant is evidence of adequate pelvic dimensions for a normal vaginal delivery. Although poor maternal nutrition can affect the health of the newborn, delivery is not necessarily affected.The muscular layer of the uterus that is the functional unit in pregnancy and labor is the:

• perimetrium
• myometrium
• endometrium
• cervix
• myometrium

Rationale: The myometrium is the middle muscular uterine layer and is functional in pregnancy and labor. The perimetrium is the outermost, or serosal, layer that envelops the uterus. The endometrium is the inner, or mucosal, layer that is functional during menstruation and implantation of the fertilized ovum. The cervix is the lower part of the uterus that lubricates the vagina, acts as a bacteriostatic agent, provides an alkaline environment, and produces a mucous plug.During a prenatal clinic visit, a woman states that she probably will not plan to breastfeed her infant because she has very small breasts and believes she cannot provide adequate milk for a full-term infant, The best response of the nurse would be:

• "Ask the physician if he or she will prescribe hormones to build up the breasts."
• "I can provide you with exercises that will build up your breast tissue."
• "The fluid intake of the mother will determine the milk output."
• "The size of the breast has no relationship to the ability to produce adequate milk."
• "The size of the breast has no relationship to the ability to produce adequate milk."

Rationale: Breast size is primarily determined by the amount of fatty tissue and is unrelated to a woman's ability to produce milk. The other answer options are inaccurate.