Test Bank for RN NCLEX Exam All Practice Questions

pg. 1 Test Bank for RN NCLEX Exam/ All Practice Questions with Correct Verified Answers/ All Chapters Covered/ Updated 2024.

Is a process of learning a different culture to adapt to a new or changing environment. - Correct Answer - Acculturation.

It is a subjective perspective of the person's heritage and a sense of belonging to a group - Correct Answer - Ethnic identity

Include meditation, relaxation techniques, imagery, music therapy, massage, touch, laughter, humor, &

spiritual measures (prayer). - Correct Answer - Low-risk therapies:

A pregnant client is seen for a regular prenatal visit and tells the nurse that she is experiencing irregular contractions. The nurse determines that she is experiencing Braxton Hicks contractions. On the basis of this finding, which nursing action is appropriate?

• Contact the primary health care provider.
• Instruct the client to maintain bed rest for the remainder of the pregnancy.
• Inform the client that these contractions are common and may occur throughout the pregnancy.
• Call the maternity unit and inform them that the client will be admitted in a preterm labor condition. -

ANSWER - C

Braxton Hicks contractions are irregular, painless contractions that may occur intermittently throughout pregnancy. Because Braxton Hicks contractions may occur and are normal in some pregnant women during pregnancy, there is no reason to notify the primary health care provider. This client is not in preterm labor and, therefore, does not need to be placed on bed rest or be admitted to the hospital to be monitored.

A client arrives at the clinic for the first prenatal assessment. She tells the nurse that the first day of her last normal menstrual period was October 19, 2020. Using Näegele's rule, which expected date of delivery should the nurse document in the client's chart? 1 / 4

pg. 2

• July 12, 2021
• July 26, 2021
• August 12, 2021
• August 26, 2021 - ANSWER - B

Accurate use of Näegele's rule requires that the woman have a regular 28-day menstrual cycle. Subtract

• months and add 7 days to the first day of the last menstrual period, and then add 1 year to that date:

first day of the last menstrual period, October 19, 2020; subtract 3 months, July 19, 2020; add 7 days, July 26, 2020; add 1 year, July 26, 2021.

The nurse is collecting data during an admission assessment of a client who is pregnant with twins. The client has a healthy 5-year-old child who was delivered at 38 weeks and tells the nurse that she does not have a history of any type of abortion or fetal demise. Using GTPAL, what should the nurse document in the client's chart?

A. G = 3, T = 2, P = 0, A = 0, L = 1

B. G = 2, T = 1, P = 0, A = 0, L = 1

C. G = 1, T = 1, P = 1, A = 0, L = 1

D. G = 2, T = 0, P = 0, A = 0, L = 1 - ANSWER - B

Pregnancy outcomes can be described with the acronym GTPAL. G is gravidity, the number of pregnancies; T is term births, the number born at term (longer than 37 weeks); P is preterm births, the number born before 37 weeks of gestation; A is abortions or miscarriages, the number of abortions or miscarriages (included in gravida if before 20 weeks of gestation; included in parity [number of births] if past 20 weeks of gestation); and L is the number of current living children. A woman who is pregnant with twins and has a child has a gravida of 2. Because the child was delivered at 38 weeks, the number of term births is 1, and the number of preterm births is 0. The number of abortions is 0, and the number of living children is 1.

The nurse is caring for a client in labor. Which assessment findings indicate to the nurse that the client is beginning the second stage of labor? Select all that apply.

• The contractions are regular.
• The membranes have ruptured.
• The cervix is dilated completely. 2 / 4

pg. 3

• The client begins to expel clear vaginal fluid.
• The Ferguson reflex is initiated from perineal pressure. - ANSWER - C, E

The second stage of labor begins when the cervix is dilated completely and ends with birth of the neonate. The woman has a strong urge to push in stage 2 when the Ferguson reflex is activated. Options 1, 2, and 4 are not specific assessment findings of the second stage of labor and occur in stage 1.

The nurse is reviewing true and false labor signs with a multiparous client. The nurse determines that the client understands the signs of true labor if she makes which statement?

• "I won't be in labor until my baby drops."
• "My contractions will be felt in my abdominal area."
• "My contractions will not be as painful if I walk around."
• "My contractions will increase in duration and intensity." - ANSWER - D

True labor is present when contractions increase in duration and intensity. Lightening or dropping leads to engagement (presenting part reaches the level of the ischial spine) and occurs when the fetus descends into the pelvis about 2 weeks before delivery. Contractions felt in the abdominal area and contractions that ease with walking are signs of false labor.

Because of their health & dietary practices, Native Americans, Latino Americans, Hispanic Americans, & African Americans. - Correct Answer - High risk of obesity & diabetes mellitus

Surgery is not prohibited, but the administration of blood and blood products is forbidden. This religious group believes the soul cannot live after death. Administration of medication is an acceptable practice except if the medication is derived from blood products. - Correct Answer - Jehovah's Witnesses

Believers adhere to dietary kosher laws. In this religion, the dairy-meat combination is unacceptable.Only fish that have scales and fins are allowed; meats that are allowed include animals that are vegetable eaters, cloven-hoofed, and ritually slaughtered. - Correct Answer - Orthodox Judaism

include whole medical systems, mind-body medicine, biologically based practices, manipulative & body- based practices, & energy medicine. - Correct Answer - Five categories of complementary and alternative

medicine (CAM): 3 / 4

pg. 4

Focused, maintains strong control, makes decisions, & addresses all problems. Dominates group & commands, rather than seeks suggestions or input. Manager addresses problem (quality improvement) with taff, designs a plan without input, & wants all problems reported directly back to her - Correct Answer - Autocratic leader

Participative & would likely meet with each staff person individually to determine staff member's perception of problem. Would also speak with the staff about any issues & ask the staff for input with developing a plan. - Correct Answer - Democratic leader

Passive and nondirective. Would state what the problem was & inform staff that the staff needed to come up with a plan to "fix it." - Correct Answer - Laissez-faire leader

Assessment findings include cough, dyspnea, crackles, tachypnea, tachycardia, elevated blood pressure, bounding pulse, elevated CVP, weight gain, edema, neck & hand vein distention, altered LOC, & decreased hematocrit. - Correct Answer - Overhydration or fluid overload & occurs when fluid intake or fluid retention

Avocado, bananas, cantaloupe, carrots, fish, mushrooms, oranges, potatoes, pork, beef, veal, raisins, spinach, strawberries, & tomatoes - Correct Answer - Common food sources of potassium:

Muscle weakness, increased urinary output, & decreased specific gravity of the urine would be noted - Correct Answer - Hyponatremia

Causative factors relate to malnutrition or starvation & the use of aluminum hydroxide-based or magnesium-based antacids. Malnutrition is associated with alcoholism. - Correct Answer - Hypophosphatemia

Renal insufficiency, hypoparathyroidism, & tumor lysis syndrome; causative factors. Should avoid foods high in phosphates; fish, eggs, milk products, vegetables, whole grains, & carbonated beverages. - Correct Answer - Hyperphosphatemia

Vomiting, diarrhea, conditions that increased respiration's or increased urinary output, insufficient intravenous fluid replacement, draining fistulas, presence of ileostomy or colostomy. Diuretics, & gastrointestinal suctioning. - Correct Answer - Causes of a fluid volume deficit

• / 4