NCLEX-RN Exam Questions - Part 78

1. A client has just been transferred to the floor from the labor and delivery unit following delivery of a stillborn term infant. She is very despondent. When the nurse attempts to take her vital signs, she responds in anger, stating, 'You leave me alone. You don - t care anything about me. It - s people like you who let my baby die.'The nurses best course of action is to:

A) Quietly leave her room, allowing her more private time to deal with her loss.
B) Tell her that what happened was for the best and that she is still young and can have other children.
C) Tell her how sorry you are, and let her know that her child is now a little angel in heaven.
D) Tell her how sorry you are about the loss of her baby, and acknowledge her anger as being a normal stage of grief. Assure her that you are there to help her in any way you can.



2. When a client arrives on the labor and delivery unit, she informs the nurse that she has been having contractions for the last 5 hours. Now the pain is constant and not cyclical as it was earlier. The nurse considers the possibility of uterine rupture. Which of the following symptoms would be consistent with a uterine rupture?

A) A large gush of clear fluid from the vagina
B) Systolic hypertension
C) Abdominal rigidity
D) Increased fetal movements



3. A mother called the physicians office to ask if it would help relieve her small daughters abdominal pain if she gave an enema and placed a heating pad on the abdomen. Her daughter has a fever and has vomited twice.The nurses response is based on the knowledge that:

A) The symptoms could easily have been caused by constipation, which an enema would relieve
B) Heat would help to relax the abdominal muscles and relieve her pain
C) Both heat and enemas stimulate intestinal motility and could increase the risk of perforation
D) Complaints of stomach ache are common in young children and are generally best ignored



4. An 8-year-old child is admitted to the hospital for surgery. She has had no previous hospitalizations, and both she and her family appear anxious and fearful. It will be most helpful for the nurse to:

A) Take the child to her room and calmly and matter-offactly begin to get her ready to go to the operating room
B) Take time to orient the child and her family to the hospital and the forthcoming events
C) Explain that as soon as the child goes to the operating room she will have time to answer any questions the family has
D) Tell the child and her family that there is nothing to worry about, that the operation will not take long, and she will soon be as 'good as new'



5. Following a bicycle accident, a 12-year-old client sustained a complete fracture of the left femur. He was placed in 90-90 skeletal traction with a pin in the distal end of the femur to achieve realignment and immobilization of the left femur. When providing nursing care, it is important for the nurse to remember that:

A) The nurse may lift only the weights that are applying traction in order to reposition him in bed
B) The client will need special skin care at the pin site according to hospital policy or the physician - s preference
C) The traction pull should result in an immediate increase in comfort and reduce the need for pain medication
D) The client should be discouraged from participating in self-care activities to avoid the risk of disrupting the traction