NCLEX RN Nursing Exam
Question 1 of 5.
The nurse assesses a client's monitor strip and finds the following: uterine contractions every 3-4 minutes, lasting 60-70 seconds; FHR baseline 134-146 bpm, with accelerations to 158 bpm with fetal movement. Which nursing intervention is appropriate?
A. Notify physician of nonreassuring FHR pattern.
B. Turn the client to her left side.
C. Start IV for fetal distress and administer O2 at 6-8 liters by mask.
D. Evaluate to see if the monitor strip is reassuring.
Explanation: These indices are within normal parameters; therefore, the nurse does not need to contact the physician. The purpose of turning a client to her left side is to maximize uteroplacental blood flow. Based on the above assessment, there is no indication that blood flow is compromised. These interventions are appropriate nursing interventions for late and prolonged decelerations. Following these interventions, the nurse should notify the physician. These indices are within normal parameters; therefore, the nurse does not need to start an IV and administer O2. Variations of 20 bpm above or below the baseline FHR is considered normal. Normal FHRs range from 120-160 bpm. As the fetus moves, the FHR increases, and accelerations often occur in concert with contractions. During the active phase of labor, the frequency of uterine contractions is every 2-4 minutes, with an appropriate duration of 60 sec.
Question 2 of 5.
A client tells the nurse that she takes St. John's wort (hypericum perforatum) three times a day for mild depression. The nurse should tell the client that:
A. St. John's wort seldom relieves depression.
B. She should avoid eating aged cheese.
C. Skin reactions increase with the use of sunscreen.
D. The herbal is safe to use with other antidepressants.
Explanation: St. John's wort increases photosensitivity, so sunscreen use may paradoxically increase skin reactions; clients should be cautioned about sun exposure.
Question 3 of 5.
An adolescent client hospitalized with anorexia nervosa is described by her parents as 'the perfect child.' When planning care for the client, the nurse should:
A. Allow her to choose what foods she will eat
B. Provide activities to foster her self-identity
C. Encourage her to participate in morning exercise
D. Provide a private room near the nurse's station
Explanation: Anorexia nervosa is often linked to issues of control and identity; activities fostering self-identity help address underlying psychological factors.
Question 4 of 5.
The mother of a child with chickenpox wants to know if there is a medication that will shorten the course of the illness. Which medication is sometimes used to speed healing of the lesions and shorten the duration of fever and itching?
A. Zovirax (acyclovir)
B. Varivax (varicella vaccine)
C. VZIG (varicella-zoster immune globulin)
D. Periactin (cyproheptadine)
Explanation: Acyclovir (Zovirax) is an antiviral that can reduce the severity and duration of chickenpox symptoms, including lesions, fever, and itching.
Question 5 of 5.
The physician has ordered an IV bolus of Solu-Medrol (methylprednisolone sodium succinate) in normal saline for a client admitted with a spinal cord injury. Solu-Medrol has been shown to be effective in:
A. Preventing spasticity associated with cord injury
B. Decreasing the need for mechanical ventilation
C. Improving motor and sensory functioning
D. Treating post injury urinary tract infections
Explanation: High-dose methylprednisolone within 8 hours of spinal cord injury can improve motor and sensory outcomes by reducing inflammation and edema.