01 NCLEX PN Practical Nurses Quiz | Practice Test 01

NCLEX PN Practical Nurses Quiz | Practice Test 01

1 >>When assessing a laboring client, the nurse finds a prolapsed cord. The nurse should: ?

• (A) Attempt to replace the cord
• (B) Place the client on her left side
• (C) Elevate the client's hips
• (D) Cover the cord with a dry, sterile gauze

Solution The client with a prolapsed cord should be treated by elevating the hips and covering the cord with a moist, sterile saline gauze. The nurse should use her fingers to push up on the presenting part until a Caesarean section can be performed.Do not attempt to replace the cord, as stated in answer A. Answer B is incorrect because turning the client to the left side will not help take pressure off the cord. Answer D is incorrect because the cord should be covered with a moist, sterile gauze, not dry gauze

2 >>The nurse is caring for a 30-year-old male admitted with a stab wound. While in the emergency room, a chest tube is inserted.Which of the following explains the primary rationale for insertion of chest tubes? ?

• (A) The tube will allow for equalization of the lung expansion.
• (B) Chest tubes serve as a method of draining blood and serous fluid, and assist in reinflating the lungs.
• (C) Chest tubes relieve pain associated with a collapsed lung.
• (D) Chest tubes assist with cardiac function by stabilizing lung expansion.

Solution Chest tubes work to reinflate the lung and drain serous fluid. The tube does not equalize expansion of the lungs, so answer A is incorrect. Pain is associated with collapse of the lung, and insertion of chest tubes is painful, so answer C is incorrect. Answer D is true but is not the primary rationale for performing chest tube insertion.

3 >>A client who delivered this morning tells the nurse that she plans to breastfeed her baby. The nurse is aware that successful breastfeeding is most dependent on the: ?

• (A) Mother's educational level
• (B) Infant's birth weight
• (C) Size of the mother's breast
• (D) Mother's desire to breastfeed

Solution Success with breastfeeding depends on many factors, but the most dependable reason for success is desire and willingness to continue the breastfeeding until the infant and mother have time to adapt. The educational level, infant's birth weight, and size of the mother's breast have nothing to do with success, so answers A, B, and C are incorrect.

4 >>The nurse is monitoring the progress of a client in labor. Which finding should be reported to the physician immediately? ?

• (A) The presence of scant bloody discharge
• (B) Frequent urination
• (C) The presence of green-tinged amniotic fluid
• (D) Moderate uterine contractions

Solution Green-tinged amniotic fluid is indicative of meconium staining.This finding indicates fetal distress. The presence of scant bloody discharge is normal,as are frequent urination and moderate uterine contractions, so answers A, B, and D are incorrect.

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5 >>The nurse is measuring the duration of the client's contractions. Which statement is true regarding the measurement of the duration of contractions? ?

• (A) Duration is measured by timing from the beginning of one contraction to the beginning of the next contraction.
• (B) Duration is measured by timing from the end of one contraction to the beginning of the next contraction.
• (C) Duration is measured by timing from the beginning of one contraction to the end of the same contraction.
• (D) Duration is measured by timing from the peak of one contraction to the end of the same contraction.

Solution Duration is measured from the beginning of one contraction to the end of the same contraction. Answer A is related to frequency. Answer B is incorrect because we do not measure from the end of the contraction to the beginning of the contraction. Duration also is not measured from the peak of the contraction to the end, as stated in answer D.

6 >>The physician has ordered an intravenous infusion of Pitocin for the induction of labor. When caring for the obstetric client receiving intravenous Pitocin, the nurse should monitor for: ?

• (A) Maternal hypoglycemia
• (B) Fetal bradycardia
• (C) Maternal hyperreflexia
• (D) Fetal movement

Solution The client receiving Pitocin should be monitored for decelerations. There is no association with Pitocin use and hypoglycemia, maternal hyperreflexia,or fetal movement, so answers A, C, and D are incorrect.

7 >>A client with diabetes visits the prenatal clinic at 28 weeks gestation. Which statement is true regarding insulin needs during pregnancy? ?

• (A) Insulin requirements moderate as the pregnancy progresses.
• (B) A decreased need for insulin occurs during the second trimester.
• (C) Elevations in human chorionic gonadotrophin decrease the need for insulin.
• (D) Fetal development depends on adequate insulin regulation.

Solution During pregnancy, insulin needs increase during the second and third trimesters; they do not decrease, as suggested in answer B. Insulin requirements do not moderate as the pregnancy progresses, so answer A is incorrect. Elevated human chorionic gonadotrophin elevate insulin needs; they do not decrease insulin needs. Thus, answer C is incorrect. Fetal development does depend on adequate nutrition and insulin regulation.134 Chapter 2

8 >>A client in the prenatal clinic is assessed to have a blood pressure of 180/96. The nurse should give priority to: ?

• (A) Providing a calm environment
• (B) Obtaining a diet history
• (C) Administering an analgesic
• (D) Assessing fetal heart tones

Solution A calm environment is needed to prevent seizure activity. Any stimulation can precipitate seizures. Assessing the fetal heart tones is important but is not the highest priority in this situation, so answer D is incorrect. Obtaining a diet history should be done later, so answer B is incorrect. Administering an analgesic is not indicated because there is no data in the stem to indicate pain, so answer C is incorrect.

9 >>A primigravida, age 42, is 6 weeks pregnant. Based on the client's age, her infant is at risk for: ?

• (A) Down syndrome
• (B) Respiratory distress syndrome
• (C) Turner's syndrome
• (D) Pathological jaundice

Solution The client who is age 42 is at risk for fetal anomalies such as Down syndrome and other chromosomal aberrations. She is not at higher risk for respiratory distress syndrome or pathological jaundice, as stated in answers B and D.Turner's syndrome, in answer C, is a genetic disorder that is not associated with age factors in pregnancy

10 >>A client with a missed abortion at 29 weeks gestation is admitted to the hospital. The client will most likely be treated with: ?

• (A) Magnesium sulfate
• (B) Calcium gluconate
• (C) Dinoprostone (Prostin E.)
• (D) Bromocrystine (Pardel)

Solution The client with a missed abortion will have induction of labor.Prostin E. is a form of prostaglandin used to soften the cervix. Magnesium sulfate is used for preterm labor and preeclampsia, not to induce labor, so answer A is incorrect.Calcium gluconate is the antidote for magnesium sulfate and is not used for this client, so answer B is incorrect. Pardel is dopamine receptor stimulant used to treat Parkinson's disease; it was used at one time to dry up breast milk but is no longer used in obstetrics, so answer D is incorrect.

11 >>A client with preeclampsia has been receiving an infusion containing magnesium sulfate. Blood pressure is 160/80, deep tendon reflexes are 1 plus, and urinary output for the past hour is 100mL. The nurse should: ?

• (A) Continue the infusion of magnesium sulfate while monitoring the client's blood pressure
• (B) Stop the infusion of magnesium sulfate and contact the physician
• (C) Slow the infusion rate and turn the client on her left side
• (D) Administer calcium gluconate and continue to monitor the blood pressure

Solution The client's blood pressure is within normal limits. The urinary output is also within normal limits. The only alteration from normal is the decreased deep tendon reflexes. The nurse should continue to monitor the blood pressure and check the magnesium level. The therapeutic level is 4.8-9.6mg/dL. There is no need to stop the infusion at this time or slow the rate, as stated in answers B and C. Calcium gluconate is the antidote for magnesium sulfate, but there is no data to indicate toxicity, so answer D is incorrect.

12 >>Which statement describes the inheritance pattern of autosomal recessive disorders? ?

• (A) An affected newborn has unaffected parents.
• (B) An affected newborn has one affected parent.
• (C) Affected parents have a one in four chance of passing on the defective gene.
• (D) Affected parents have unaffected children who are carriers.

Solution Autosomal recessive disorders can be passed from the parents to the infant if each parent passes the defective gene. If both parents pass the trait, the child will get two abnormal genes, and the disease results. The parents can also pass the trait to the infant. Answer A is incorrect because, to have an affected newborn, the parents must be carriers. Answer B is incorrect because both parents must be carriers.Answer D is incorrect because the parents can have affected children.

13 >>A pregnant client, age 32, asks the nurse why her doctor has recommended a serum alpha fetoprotein. The nurse should explain that the doctor has recommended the test: ?

• (A) Because it is a state law
• (B) To detect cardiovascular defects
• (C) Because of her age
• (D) To detect neurological defects

Solution Alpha fetoprotein is a screening test done to detect neural tube defects such as spina bifida. The test is not mandatory, as stated in answer A; it does not indicate cardiovascular defects, as suggested in answer B; and her age has no bearing on the need for the test, as suggested in answer C.

14 >>A client with hypothyroidism asks the nurse if she will still need to take thyroid medication during the pregnancy. The nurse's response is based on the knowledge that: ?

• (A) There is no need to take thyroid medication because the fetus's thyroid produces thyroid-stimulating hormones.
• (B) Regulation of thyroid medication is more difficult because the thyroid gland increases in size during pregnancy.
• (C) It is more difficult to maintain thyroid regulation during pregnancy due to a slowing of metabolism.
• (D) Fetal growth is arrested if thyroid medication is continued during pregnancy.

Solution During pregnancy, the thyroid gland triples in size. This makes it more difficult to regulate thyroid medication. Answer A is incorrect because there might be a need for thyroid medication during pregnancy. Answer C is incorrect because the thyroid function does not slow. Answer D is incorrect because fetal growth is not arrested if thyroid medication is continued.

15 >>The nurse is responsible for performing a neonatal assessment on a full-term infant. At 1 minute, the nurse could expect to find: ?

• (A) An apical pulse of 100
• (B) Absence of tonus
• (C) Cyanosis of the feet and hands
• (D) Jaundice of the skin and sclera

Solution Cyanosis of the feet and hands is acrocyanosis. This is a normal finding 1 minute after birth. Answers A and B are incorrect because an apical pulse should be 120-160 and the baby should have muscle tone. Jaundice immediately after birth is pathological jaundice and is abnormal, so answer D is incorrect. Practice Exam 2 and Rationales 135

16 >>A client with sickle cell anemia is admitted to the labor and delivery unit during the first phase of labor. The nurse should anticipate the client's need for: ?

• (A) Supplemental oxygen
• (B) Fluid restriction
• (C) Blood transfusion
• (D) Delivery by Caesarean section

Solution Clients with sickle cell crises are treated with heat, hydration, oxygen, and pain relief. Fluids are increased, not decreased, so answer B is incorrect.Answer C is incorrect because blood transfusions are usually not required. Answer D is incorrect because these clients can be delivered vaginally.

17 >>A client with diabetes has an order for ultrasonography. Preparation for an ultrasound includes: ?

• (A) Increasing fluid intake
• (B) Limiting ambulation
• (C) Administering an enema
• (D) Withholding food for 8 hours

Solution Before ultrasonography, the client should be taught to drink plenty of fluids and not void. The client may ambulate, so answer B is incorrect. An enema is not needed, and there is no need to withhold food for 8 hours, so answers C and D are incorrect.

18 >>An infant who weighs 8 pounds at birth would be expected to weigh how many pounds at 1 year? ?

• (A) 14 pounds
• (B) 16 pounds
• (C) 18 pounds
• (D) 24 pounds

Solution By 1 year of age, the infant is expected to triple his birth weight.Answers A, B, and C are incorrect because these weights are too low.

19 >>A pregnant client with a history of alcohol addiction is scheduled for a nonstress test. The nonstress test: ?

• (A) Determines the lung maturity of the fetus
• (B) Measures the activity of the fetus
• (C) Shows the effect of contractions on the fetal heart rate
• (D) Measures the neurological well-being of the fetus

Solution A nonstress test is done to evaluate periodic movements of the fetus. It is not done to evaluate lung maturity. Answer A is incorrect because a nonstress test does not measure lung maturity. An oxytocin challenge test shows the effect of contractions on fetal heart rate; this makes answer C incorrect. A nonstress test does not measure the neurological well-being of the fetus, so answer D is incorrect.

20 >>A full-term male has hypospadias. Which statement describes hypospadias? ?

• (A) The urethral opening is absent.
• (B) The urethra opens on the dorsal side of the penis.
• (C) The penis is shorter than usual.
• (D) The urethra opens on the ventral side of the penis.

Solution Hypospadia is a condition in which the urethra opens on the dorsal side of the penis. Answer A is incorrect because there is an opening. Answer C is incorrect because the penis is the correct size. Answer D is incorrect because the opening is on the dorsal side, not the ventral side.

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