NCLEX-PN TEST BANK

Safe and Effective Care Environment Nclex PN Questions

Which hormone in the urine is specifically indicative of pregnancy?

    A. estrogen

    B. progesterone

    C. testosterone

    D. human chorionic gonadotropin

Correct Answer: human chorionic gonadotropin
Rationale: Human chorionic gonadotropin is the hormone specifically indicative of pregnancy as it is produced by the placenta after implantation. It can be detected in urine and blood samples to confirm pregnancy. Estrogen and progesterone play crucial roles in the menstrual cycle and pregnancy but are not specific indicators of pregnancy on their own. Testosterone is a hormone primarily associated with male reproductive functions and is not directly related to pregnancy, making it an incorrect choice in this context.

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: decrease maternal fluids
Rationale: When fetal distress is indicated, interventions are aimed at improving oxygenation and blood flow to the fetus. Increasing maternal fluids helps improve blood flow and oxygen delivery, administering oxygen increases oxygenation levels, and turning the mother can help optimize fetal oxygenation. Decreasing maternal fluids would negatively impact blood volume and can worsen fetal distress, making it the exception among the listed interventions. Therefore, decreasing maternal fluids should not be performed when fetal distress is present.

A health care provider asks the nurse caring for a client with a new colostomy to request the hospital’s stoma nurse to visit the client and assist with colostomy care. The nurse initiates the consultation, understanding that the stoma nurse will be able to influence the client because of which type of power?

  • A. Expert power
  • B. Referent power
  • C. Coercive power
  • D. Reward power

Correct Answer: Expert power
Rationale: Power is the ability to influence others to achieve goals. Expert power results from knowledge and skills that one possesses that are needed by others. In this scenario, the stoma nurse's expertise in colostomy care gives them the ability to influence the client effectively. Reward power is based on the ability to grant rewards and favors, which is not applicable in this situation. Coercive power is based on fear and the ability to punish, which is not the case in seeking assistance for colostomy care. Referent power results from followers' desire to identify with a powerful person, which is not the primary influence in this context.

What is the appropriate ratio of cardiac compressions to ventilations in an adult client for one-person CPR?

  • A. 5:1
  • B. 1:5
  • C. 15:2
  • D. 2:15

Correct Answer: 15:2
Rationale: The correct answer is 15:2. For one-person CPR on an adult, the ratio of compressions to ventilations is 15:2. This ratio ensures adequate oxygenation while maintaining effective circulation. Choice A (5:1) and Choice B (1:5) are incorrect ratios and do not align with the recommended guidelines for adult CPR. Choice D (2:15) is also incorrect as it reverses the order of compressions and ventilations.

Under what circumstances can an individual receive medical care without giving informed consent?

  • A. when the durable power of attorney for health care is not available
  • B. in an emergency, life-or-death situation
  • C. when the physician is not available for discussion with the client
  • D. when they (clients) are not able to speak for themselves

Correct Answer: in an emergency, life-or-death situation
Rationale: An individual may receive medical care without giving informed consent in an emergency, life-or-death situation. This exception allows healthcare providers to provide immediate treatment to save a person's life or prevent serious harm when time is of the essence. Choices A, C, and D are incorrect because in all other situations, informed consent is required. The durable power of attorney for health care should be involved if available, the physician should have a discussion with the client in non-life-threatening situations, and in cases where clients are unable to speak for themselves, their designated representative or responsible party should be involved in the consent process.

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