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. While undergoing fetal heart monitoring, a pregnant Native-American woman requests that a medicine woman be present in the examination room. Which of the following is an appropriate response by the nurse?
- A. "I will assist you in arranging to have a medicine woman present."?
- B. "We do not allow medicine women in exam rooms."?
- C. "That does not make any difference in the outcome."?
- D. "It is old-fashioned to believe in that."?
Correct answer: A
Rationale: The correct response is to show cultural awareness and acceptance by offering to assist in arranging for the medicine woman to be present. This demonstrates respect for the client's beliefs and preferences. Choice B is inappropriate as it dismisses the client's request without considering its cultural significance. Choice C is dismissive and does not acknowledge the client's values. Choice D is disrespectful and judgmental, undermining the client's beliefs. Therefore, the only appropriate and professional response is to support the client's request and offer assistance in accommodating it.
3. The nurse has completed client teaching about introducing solid foods to an infant. To evaluate teaching, the nurse asks the mother to identify an appropriate first solid food. Which of the following is an appropriate response?
- A. pureed canned squash
- B. pureed apples
- C. yogurt
- D. infant rice cereal
Correct answer: D
Rationale: The correct answer is infant rice cereal. Single-grain infant cereals are recommended as the first solid food because they are easily digestible and have added iron content. Choice C, yogurt, is incorrect because yogurt is a milk product and should be delayed until the child is 12 months old due to the risk of milk allergy. Choices A and B are incorrect because fruits and vegetables are typically introduced after cereals to help the infant get accustomed to solid foods gradually.
4. A nurse is assisting a new nursing graduate with organizational skills in delivering client care. The nurse determines that the new nursing graduate needs assistance with time management if the new graduate takes which action?
- A. Gathers supplies before beginning a task
- B. Allows time for unexpected tasks
- C. Prioritizes client needs and daily tasks
- D. Documents task completion and client information at the end of the day
Correct answer: A
Rationale: The correct answer is 'Gathers supplies before beginning a task.' This action indicates a lack of effective time management because gathering supplies before starting a task can lead to inefficiency and time wastage. Effective time management involves organizing tasks efficiently, which includes having all necessary supplies ready before initiating a task. Allowing time for unexpected tasks, prioritizing client needs and daily tasks, and documenting task completion and client information at the end of the day are all essential components of good time management practices. Therefore, the new nursing graduate should focus on improving the timing of supply gathering to enhance time management skills. The other choices are not indicative of poor time management; instead, they demonstrate important aspects of effective time management in client care delivery.
5. What condition is mammography used to detect?
- A. pain
- B. tumor
- C. edema
- D. epilepsy
Correct answer: B
Rationale: Mammography is specifically used to detect tumors or abnormal growths, especially in breast tissue. It is not a tool for identifying pain, edema, or epilepsy. Therefore, the correct answer is 'tumor.' Pain is a symptom, edema is swelling, and epilepsy is a neurological disorder; none of these are conditions typically detected through mammography.
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