NCLEX-PN
NCLEX PN Test Bank
1. All of the following interventions should be performed when fetal heart monitoring indicates fetal distress except:
- A. Increase maternal fluids.
- B. Administer oxygen.
- C. Decrease maternal fluids.
- D. Turn the mother.
Correct answer: C
Rationale: When fetal heart monitoring indicates fetal distress, interventions are aimed at improving oxygenation to the fetus. Increasing maternal fluids helps improve placental perfusion and oxygen delivery to the fetus. Administering oxygen also aids in increasing oxygen supply to the fetus. Turning the mother can help relieve pressure on the vena cava, optimizing blood flow to the placenta. Therefore, decreasing maternal fluids would not be performed as it can further compromise placental perfusion and fetal oxygenation, making it the exception. Decreasing maternal fluids could potentially exacerbate fetal distress by reducing oxygen delivery and nutrient supply to the fetus, which is contrary to the goal of managing fetal distress.
2. When managing nausea related to Morphine epidural analgesia, the nurse should administer:
- A. Indomethacin
- B. Codeine
- C. Ibuprofen
- D. Compazine
Correct answer: D
Rationale: When managing nausea related to Morphine epidural analgesia, Compazine is the appropriate medication to administer. Compazine, also known as prochlorperazine, is commonly used to treat nausea and vomiting. It works by affecting certain chemicals in the brain that trigger nausea and vomiting. Choices A, B, and C are incorrect because Indomethacin, Codeine, and Ibuprofen are not typically used to manage nausea associated with Morphine epidural analgesia.
3. What does carrying a donor card for organ donation mean?
- A. medical care is altered to obtain organs for donation in the event of serious injuries
- B. the family or legally responsible party of a client has no decision-making authority in the event that the client is considered for organ donation
- C. a client is allowed to revoke their decision for organ donation at any time
- D. a client is considered an organ donor for multiple organs or tissues
Correct answer: C
Rationale: Carrying a donor card for organ donation signifies that an individual can decide to revoke their decision for organ donation at any point. This choice empowers the individual to change their mind regarding organ donation. The family or legally responsible party of a client still holds decision-making authority in the event that the client is considered for organ donation. When organ donation is being considered, all organs or tissues the donor wishes to donate are evaluated for donation suitability; it's not limited to just one organ or tissue. It's important to note that medical care for an individual is not altered to hasten the declaration of death for organ donation purposes; the focus is on providing immediate care and resuscitation to the individual.
4. Hearing screening of prematurely born infants is an effective means of identifying disease and is an example of:
- A. Primary prevention.
- B. Secondary prevention.
- C. Tertiary prevention.
- D. Disability prevention.
Correct answer: B
Rationale: The correct answer is B: Secondary prevention. Hearing screening for prematurely born infants falls under secondary prevention, which aims to identify and treat a condition in its early stages to prevent further complications. Primary prevention (choice A) focuses on preventing the disease from occurring, while tertiary prevention (choice C) involves managing complications and preventing disability. Choice D, disability prevention, is not a recognized category of prevention. In this context, the screening helps in early identification of hearing loss, allowing for timely intervention to prevent further impairment or complications, aligning with the principles of secondary prevention.
5. Which of the following nursing diagnoses might be appropriate as Parkinson's disease progresses and complications develop?
- A. Impaired Physical Mobility
- B. Dysreflexia
- C. Hypothermia
- D. Impaired Dentition
Correct answer: A
Rationale: As Parkinson's disease progresses and complications develop, impaired physical mobility is a relevant nursing diagnosis due to symptoms like a shuffling gait and rigidity that can impair movement. Dysreflexia is not typically associated with Parkinson's disease; it is more commonly seen in spinal cord injuries. Hypothermia is a condition of low body temperature and is not directly related to Parkinson's disease progression. Impaired Dentition involves issues with teeth and oral health, which are not specific to Parkinson's disease complications.
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