NCLEX-RN
NCLEX RN Exam Review Answers
1. As you are assessing the fetus during labor, you are determining the fetal lie, presentation, attitude, station, and position. Your client asks you what all these assessments are. Among other things, how should you respond to the mother?
- A. You should explain that fetal lie is where the fetus's presenting part is within the birth canal during labor, among other information about the other assessments.
- B. You should explain that fetal presentation is the relationship of the fetus's spine to the mother's spine, among other information about the other assessments.
- C. You should explain that fetal attitude is the relationship of the fetus's presenting part to the anterior, posterior, right, or left side of the mother's pelvis, among other information about the other assessments.
- D. You should explain that fetal station is the level of the fetus's presenting part in relationship to the mother's ischial spines, among other information about the other assessments.
Correct answer: D
Rationale: You should explain that fetal station is the level of the fetus's presenting part in relationship to the mother's ischial spines. Fetal station is measured in terms of the number of centimeters above or below the mother's ischial spines. When the fetus is 1 to 5 centimeters above the ischial spines, the fetal station is -1 to -5, and when the fetus is 1 to 5 centimeters below the level of the maternal ischial spines, the fetal station is +1 to +5. Choices A, B, and C provide incorrect information about fetal lie, presentation, and attitude, respectively, which do not align with the definitions of these terms in obstetrics.
2. A 58-year-old client is being tested for rheumatoid arthritis. Her physician orders an erythrocyte sedimentation rate (ESR). Which of the following results is most likely to be associated with arthritis?
- A. 5 mm/hr
- B. 12 mm/hr
- C. 28 mm/hr
- D. 40 mm/hr
Correct answer: D
Rationale: The erythrocyte sedimentation rate (ESR) measures levels of inflammation in the body. Elevated ESR levels are commonly seen in autoimmune conditions like rheumatoid arthritis due to the presence of inflammation. In women over 50 years old, a normal ESR is typically below 30 mm/hr. Therefore, a result of 40 mm/hr is more indicative of arthritis in a 58-year-old individual. Choices A, B, and C are below the normal ESR range for a woman of this age and would not be as strongly associated with arthritis.
3. A family member is complaining that the lights are too dim in the middle of the night when she comes in to visit her husband. What is the most objective response?
- A. Patients sleep better with the lights dimmed.
- B. The nightshift nurses prefer to work with less light.
- C. It's time for him to sleep, and you should, too.
- D. There's a reason we do that. Let me share a research study with you.
Correct answer: D
Rationale: The most objective response in this situation is to explain to the family member that there is a specific reason for dimming the lights and offer to share a research study to provide evidence-based information. By doing so, it helps the family member understand that the care provided is based on established practices and research, potentially alleviating her concerns and ensuring that her husband receives appropriate care. Choices A, B, and C do not address the family member's concern or provide a rationale backed by evidence, making them less suitable responses in this context.
4. Which of the following is a true statement about assessing blood pressure by palpation?
- A. Only the diastolic blood pressure can be assessed through palpation.
- B. The palpation technique is most useful for infants and small children.
- C. Hypertension is a common condition that might need to be assessed through blood pressure palpation.
- D. Only the systolic blood pressure can be assessed through palpation.
Correct answer: D
Rationale: When assessing blood pressure by palpation, it is important to note that only the systolic blood pressure can be determined accurately using this method. Diastolic blood pressure cannot be reliably assessed through palpation. The palpation technique is particularly useful in situations where traditional blood pressure measurement methods are challenging, such as in infants, small children, or individuals with low blood pressure that is difficult to hear. Hypertension, a common condition characterized by elevated blood pressure, is typically assessed using auscultation rather than palpation. Therefore, the correct statement is that only the systolic blood pressure can be assessed through palpation.
5. Which of the following is an example of effective time management?
- A. Always agreeing to others' requests for help
- B. Arranging long meetings to discuss important data
- C. Using multiple forms of technology to communicate or educate others
- D. Working in a secluded area to minimize interruptions
Correct answer: D
Rationale: Effective time management involves strategies that help individuals focus and complete tasks efficiently. Working in a secluded area to minimize interruptions is an example of effective time management as it allows for concentration and productivity without distractions. Choices A, B, and C are not examples of effective time management. Always agreeing to others' requests for help can lead to overcommitment and time mismanagement. Arranging long meetings can be counterproductive as they consume time that could be used for actual work. Using multiple forms of technology, though helpful, can lead to information overload and inefficiency if not managed properly. Therefore, the most effective choice for optimal time management in this scenario is working in a secluded area to minimize interruptions.
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