a primigravida begins labor when her family is unavailable and she is alone she is very upset that her family is not with her which approach can the n

NCLEX-PN

Nclex Exam Cram Practice Questions

1. A primigravida begins labor when her family is unavailable and she is alone. She is very upset that her family is not with her. Which approach can the nurse take to meet the client's needs at this time?

A. asking whether another individual wants to be her support person
B. assuring her that a nursing staff member will be with her at all times
C. telling her you will try to locate her family
D. reinforcing the woman's confidence in her own abilities to cope and maintain a sense of control

Correct answer: A

Rationale: In this situation, the best approach for the nurse is to ask whether another individual wants to be the client's support person. This empowers the client to choose someone to be with her until her family can join her, providing the needed support and comfort. Assuring her that a nursing staff member will be with her at all times (Choice B) may not fully address her emotional needs for familiar support. Telling her you will try to locate her family (Choice C) may not be feasible in the immediate situation and may not provide immediate emotional support. While reinforcing the woman's confidence in her own abilities (Choice D) is important, it may not fully address her current need for emotional support and presence of a companion.

2. The LPN is auscultating for bowel sounds and hears between 3 and 4 bowel sounds per minute. This is a somewhat expected finding for which of these clients?

A. a 63-year-old female undergoing chemotherapy for breast cancer
B. a 56-year-old female with dementia undergoing a swallow study
C. a 34-year-old male with a PEG tube newly admitted for diabetic ketoacidosis
D. a 45-year-old male recovering from a knee replacement under general anesthesia

Correct answer: D

Rationale: When recovering from general anesthesia, hypoactive bowel sounds can be expected due to the effects of the anesthesia on gut motility. For the other clients, hearing less than 5 bowel sounds per minute would indicate an abnormal finding. In the context of the given situation, the client recovering from knee replacement surgery aligns with the expected range of bowel sounds post-general anesthesia. Therefore, choice D is the correct answer. Choices A, B, and C present scenarios where hearing less than 5 bowel sounds per minute would be abnormal, indicating potential issues that need further evaluation.

3. Nonpharmacological pain management involves all of the following except:

A. hypnosis alone.
B. psychological care, including support groups.
C. physical and psychological modalities.
D. pain-reducing drugs only.

Correct answer: D

Rationale: Nonpharmacological pain management encompasses various strategies like hypnosis, psychological care, and physical and psychological modalities. The correct answer is 'pain-reducing drugs only' because nonpharmacological approaches do not solely rely on medications for pain management. Options A, B, and C are all valid components of nonpharmacological pain management. Hypnosis can help manage pain, psychological care including support groups can provide emotional support and coping strategies, and physical and psychological modalities encompass a wide range of interventions beyond just medication.

4. A nurse in a medical-surgical unit overhears the nursing staff openly discussing a client and stating that the client is uncooperative and a real pain to care for. The nurse would most appropriately manage this issue by taking which action?

A. Leaving articles about judgmental opinions in the nurses' report room
B. Reporting the nurses' comments to administration
C. Discouraging the judgmental comments
D. Ignoring the comments made about the client

Correct answer: C

Rationale: Nurses must discuss clients in a professional manner and avoid using judgmental language such as 'uncooperative' or 'difficult.' When such comments and language are discouraged, fewer comments will be made. Ignoring the comments is an inappropriate option because the concern will not be addressed. Leaving articles about judgmental opinions in the nurses' report room indirectly addresses the issue, but there is no guarantee that the staff will read them. Reporting the nurses' comments to administration does not directly address the issue. The best approach for the nurse is to discourage judgmental comments directly with the staff members. Since this action is not provided in the options, discouraging judgmental comments is the most appropriate way to manage this concern.

5. Which fetal heart monitor pattern can indicate cord compression?

A. variable decelerations
B. early decelerations
C. bradycardia
D. tachycardia

Correct answer: A

Rationale: Variable decelerations can indicate cord compression as they are caused by umbilical cord compression or prolapse. This pattern shows an abrupt decrease in heart rate with an erratic shape, often resembling a V or W. Early decelerations (choice B) are typically caused by head compression during contractions and are considered benign. Bradycardia (choice C) is a consistent low heart rate below 110 bpm and is not specific to cord compression. Tachycardia (choice D) is an abnormally high heart rate above 160 bpm and is not associated with cord compression.