the nurse is caring for a woman 2 hours after a vaginal delivery documentation indicates that the membranes were ruptured for 36 hours prior to delive

NCLEX-RN

NCLEX RN Practice Questions Quizlet

1. The nurse is caring for a woman 2 hours after a vaginal delivery. Documentation indicates that the membranes were ruptured for 36 hours prior to delivery. What are the priority nursing diagnoses at this time?

A. Altered tissue perfusion
B. Risk for fluid volume deficit
C. High risk for hemorrhage
D. Risk for infection

Correct answer: D

Rationale: The correct answer is 'Risk for infection.' When membranes are ruptured for over 24 hours before delivery, there is a significantly increased risk of infection for both the mother and the newborn. Factors such as increased local cytokines, an imbalance in enzyme activity, and increased intrauterine pressure contribute to this risk. 'Altered tissue perfusion' is not the priority in this scenario as there is no indication of compromised blood flow. 'Risk for fluid volume deficit' is not the priority as there are no signs of excessive fluid loss. 'High risk for hemorrhage' is not the priority as the question does not suggest active bleeding as an immediate concern.

2. A nurse is assisting a pregnant client who is having an amniocentesis. Which of the following statements by the nurse indicates the correct teaching for this procedure?

A. I'm going to help you lie lat on your back for this."
B. Don't worry, I'm sure everything will be all right."
C. I will need to help you remove your shirt for this procedure."
D. Now that the procedure is inished, I will put a small bandage over the puncture site."

Correct answer: D

Rationale: An amniocentesis is performed to draw amniotic luid from the sac around the fetus during pregnancy. It may be analyzed for certain disorders or complications associated with pregnancy. Following the procedure, the nurse should wash the client's abdomen and place a small bandage over the puncture site

3. Which of the following is an example of intragroup conflict?

A. A nurse writes a grant for a non-profit organization to raise money for advertising
B. Members of a multidisciplinary team cannot agree on the best course of action for a client
C. A client does not receive his medication on time because the nurse was on break
D. A nurse feels frustrated that her employer does not provide on-site child care

Correct answer: B

Rationale: Intragroup conflict refers to disagreements within a group. The correct answer, 'Members of a multidisciplinary team cannot agree on the best course of action for a client,' exemplifies this type of conflict well. In this scenario, professionals within the same team are unable to reach a consensus on how to proceed with client care. Choices A, C, and D do not reflect intragroup conflict. Writing a grant for a non-profit organization, a client not receiving medication due to a nurse's break, and a nurse feeling frustrated about the lack of on-site child care do not involve conflicts within a group of professionals.

4. The priority goal for a family who practices Chinese medicine would be to:

A. Achieve harmony
B. Maintain a balance of energy
C. Respect life
D. Restore yin and yang

Correct answer: D

Rationale: In Chinese medicine, the concept of yin and yang represents the balance of opposing forces in the body. When there is an imbalance between yin and yang, it can result in illness. Therefore, the priority goal for a family practicing Chinese medicine would be to restore the harmony and balance between yin and yang. Choices A, B, and C are not the priority goal in Chinese medicine. While achieving harmony, maintaining a balance of energy, and respecting life are important aspects of Chinese medicine, the fundamental principle revolves around maintaining the equilibrium of yin and yang for optimal health.

5. A client has been administered ketamine by a physician in preparation for general anesthesia. Which of the following side effects should the nurse monitor for in this client?

A. Delirium
B. Muscle rigidity
C. Hypotension
D. Pinpoint rash

Correct answer: A

Rationale: Ketamine is an anesthetic that induces dissociation and lack of awareness in a client. It can be used before general anesthesia or during short procedures for sedation. Ketamine may lead to side effects such as delirium, hallucinations, hypertension, and respiratory depression. Therefore, the nurse should monitor the client for delirium, as it is a potential side effect associated with ketamine use. Muscle rigidity, hypotension, and pinpoint rash are not typically attributed to ketamine administration and are less likely to occur in this scenario.