NCLEX STUDY GUIDE 2024 EXAM WITH

NCLEX STUDY GUIDE 2024 EXAM WITH

CORRECT SOLUTIONS

The charge nurse has received a change of shift report on the following laboring clients.The nurse should give priority for treatment to a

• Client who is 41 weeks pregnant, G2P1, pushing, facial presentation.
• Client who is 39 weeks pregnant, G3P2, amniotomy performed, thin, green fluid.
• Client who is 38 weeks pregnant, G1P0, oxytocin infusing, no cervical dilation in 3 hours.
• Client who is 28 weeks pregnant, G2P1, uterine contractions every 5 minutes, 4 centimeters dilated. -

Correct Answer - 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

• Has nausea and vomiting
• Has sepsis and hypotension
• Is taking large doses of thiazide diuretics
• Has decreased oral intake and is dehydrated - Correct Answer - 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?

• Perform a bladder scan
• Reassess urine output in 1 hour
• Administer 40 mg of furosemide
• Administer a 500 mL IV fluid bolus - Correct Answer - 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?

• Uses slight pressure and rotates the tube during insertion
• Advance the nasogastric tube while the client swallows water
• Flushes tube with normal saline after insertion to confirm patency
• Measures tube length from nose, to the earlobe, and then to the xiphoid process - Correct Answer -
• 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:

• Position the client in high-Fowler.
• Determine the needed tube length
• Lubricate and inset the tube, aiming towards the back of the throat and down towards the ear.
• Instruct the client to put chin to chest and repeatedly swallow during insertion.
• Stop insertion once the desired length is reached. Remove and start over if the tube meets resistance

or the client experiences respiratory distress.

• Secure with tape.
• Confirm tube placement is in the stomach and not the lungs with an X-ray before utilizing. Without

confirmation, aspiration could occur. After initial verification with an X-ray, tube placement is verified before each use by aspirating gastric contents or pH testing aspirated contents.

Takeaway:

Nasogastric tubes enter the nares and end in the stomach.Nasogastric tube placement must be confirmed with X-ray prior to use to avoid aspiration.The nurse has received information about assigned clients.Which of the following clients has an increased risk for hypocalcemia?

• Client recovering from recent thyroidectomy
• Older adult client who has viral gastroenteritis infection
• Client who has breast cancer newly metastasized to the ribs
• Client who has syndrome of inappropriate antidiuretic hormone secretion (SIADH) - Correct Answer -
• Client recovering from recent thyroidectomy

explanation: come back to finish

The pediatric nurse assesses multiple clients.Which of the following clients should the nurse INVESTIGATE further for potential child abuse?

• 1 year old client who has bright red cheeks and a raised, bumpy rash bilaterally on the arms and legs
• A 5 month old client who has influenza and a 4 cm bluish-gray asymmetrical marking on the left

buttocks

• A 10 year old client who has scratched shins and a clavicle fracture and reports falling while

skateboarding

• A 7 month old client with palm burns whose caregiver says the client climbed up the sink and grabbed

a hot iron - Correct Answer - D. A 7 month old client with palm burns whose caregiver says the client climbed up the sink and grabbed a hot iron The nurse is carting for a 8kg, 1 year old client who underwent a complete cardiac repair for tetralogy of pallor 8 hours ago.Which of the following findings would REQUIRE IMMEDIATE follow-up? Select all that apply

• 1+ radial and femoral pulses
• Temperature of 100 F (37.7 C)
• Urine output of 5 mL in the last hour
• Pinkish-tan colored chest tube drainage
• Chest tube drainage of 19 mL in one hour
• Median sternotomy dressing has 2 mL of dried blood. - Correct Answer - A. 1+ radial and femoral

pulses

• Urine output of 5 mL in the last hour