mrs d is a pregnant client who is 33 weeks gestation and is admitted for bright red vaginal bleeding her physician suspects placenta previa all of th mrs d is a pregnant client who is 33 weeks gestation and is admitted for bright red vaginal bleeding her physician suspects placenta previa all of th
Logo

Nursing Elites

NCLEX NCLEX-RN

NCLEX RN Exam Preview Answers

1. Mrs. D is a pregnant client who is 33 weeks' gestation and is admitted for bright red vaginal bleeding. Her physician suspects placenta previa. All of the following nursing interventions are appropriate for this client except:

Correct answer: Perform a vaginal exam to assess cervical dilation

Rationale: A client with placenta previa has part of the placenta covering some or all of the cervical opening. Performing a vaginal exam for placenta previa may cause significant bleeding and should be avoided unless directed by a physician, and preparations are made for emergency delivery. **Choice A** is correct as complete bed rest is essential to decrease the risk of further bleeding. **Choice B** is appropriate as assessing uterine tone helps in determining the condition of the uterus and can provide important information for the healthcare team. **Choice D** is also a necessary intervention as monitoring and recording blood loss is crucial in assessing the client's condition and response to treatment.

2. A client undergoing presurgical testing before a total abdominal hysterectomy says to the nurse, 'After I have this surgery I know my husband will never come near me again.' Which response would the nurse give?

Correct answer: You're concerned about how your husband will respond to your surgery.

Rationale: The correct response acknowledges the client's expressed concern about her husband's reaction to the surgery, encouraging further discussion without imposing the nurse's assumptions. Choice A reframes the client's concern to focus on the husband's response, aligning more closely with the client's stated worry. Choice B makes an assumption about the client's concerns regarding sexual relations, which may not be the primary focus of her statement. Choice C shifts the attention to how others perceive the client, deviating from the client's specific reference to her husband's reaction, thus not addressing the client's main concern.

3. For a healthcare worker under normal conditions with unsoiled hands, effective hand hygiene between patients requires which of the following?

Correct answer: C: Use of an alcohol-based antiseptic hand-rub

Rationale: Effective hand hygiene between patients for a healthcare worker with unsoiled hands involves using an alcohol-based antiseptic hand rub. This method is sufficient for cleaning hands that are not visibly soiled. The use of an antimicrobial soap or a prolonged scrubbing time is unnecessary and not recommended in this scenario. Wearing a mask is not required for routine hand hygiene and does not contribute to effective hand cleaning.

4. A client has entered disseminated intravascular coagulation (DIC) after becoming extremely ill after surgery. Which of the following laboratory findings would the nurse expect to see with this client?

Correct answer: Prolonged PT

Rationale: In disseminated intravascular coagulation (DIC), a client experiences widespread clotting throughout the body, leading to the depletion of clotting factors and platelets. A prolonged prothrombin time (PT) is a common finding in DIC. The PT measures the extrinsic pathway of the clotting cascade and reflects how quickly blood can clot. In DIC, the consumption of clotting factors results in a prolonged PT, indicating impaired clotting ability. Elevated fibrinogen levels (Choice A) are typically seen in the early stages of DIC due to the body's attempt to compensate for clot breakdown. Elevated platelet count (Choice C) is not a typical finding in DIC as platelets are consumed during the widespread clotting. A depressed d-dimer level (Choice D) is also not expected in DIC as d-dimer levels are elevated due to the breakdown of fibrin clots. Therefore, the correct answer is a prolonged PT.

5. A child is diagnosed with a Greenstick Fracture. Which of the following most accurately describes the broken bone?

Correct answer: a partial break in a long bone

Rationale: A Greenstick Fracture is commonly found in children due to their bones being more flexible. This type of fracture occurs when a bone bends and partially breaks, resembling what happens when a green stick from a tree is bent in half. Therefore, the most accurate description of a Greenstick Fracture is 'a partial break in a long bone.' Choice A, 'compound fracture of the fibula,' is incorrect as a Greenstick Fracture is not a compound fracture. Choice C, 'fracture of the growth plate of the ulna near the wrist,' is incorrect as it describes a different type of fracture. Choice D, 'Colles fracture of the tibia,' is incorrect as it refers to a specific type of fracture in a different bone.

Similar Questions

Which of the following examples indicates that the nurse is giving recognition as a form of therapeutic communication?
A client who exhibits blurred and double vision and muscular weakness is informed of the diagnosis of multiple sclerosis (MS). The client becomes visibly upset. Which response would the nurse make?
A client is admitted for a head injury. His body is lying in an abnormal position and the physician states he is exhibiting decorticate posturing. Based on this assessment, the nurse can expect to find the client with:
Why should a palpated pressure be performed before auscultating blood pressure?
A client is discharged following hospitalization for congestive heart failure. The nurse teaching the family suggests they encourage the client to rest frequently in which of the following positions?

Access More Features

NCLEX Basic

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access @ $69.99

NCLEX Basic

  • 5,000 Questions and answers
  • Comprehensive NCLEX Coverage
  • 90 days access @ $69.99