NCLEX RN Questions with Detailed Explanations

NCLEX RN Questions with Detailed Explanations Related

Review NCLEX RN Questions with Detailed Explanations related questions and content

The nurse is caring for a client in labor who has butorphanol tartrate prescribed for the relief of labor pain. During the administration of the medication, the nurse should ensure that which priority item is readily available?

  • A. Naloxone
  • B. Meperidine hydrochloride
  • C. An intravenous form of an antiemetic
  • D. An intravenous solution of normal saline
Correct Answer: A

Rationale: Butorphanol tartrate is an opioid analgesic that provides systemic pain relief during labor. The nurse should ensure that naloxone and resuscitation equipment are readily available to treat respiratory depression, should it occur. Meperidine hydrochloride is also an opioid analgesic that may be used for pain relief, but it also causes respiratory depression. Although an antiemetic may be prescribed for vomiting, antiemetics may enhance the respiratory depressant effects of the butorphanol tartrate. Although an IV access is desirable, the administration of normal saline is unrelated to the administration of this medication.

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The nurse is assessing the perineal changes of a woman in the second stage of labor. The nurse expects to see which of the following changes?

  • A. Anterior-posterior slit.
  • B. Oval opening.
  • C. Circular shape.
  • D. Crowning.
Correct Answer: D

Rationale: Crowning, when the fetal head is visible at the vaginal opening, is the expected perineal change in the second stage of labor, indicating imminent delivery.

A 57-year-old Hispanic woman with breast cancer who does not speak English is admitted for a lumpectomy. Her daughter, who speaks English, accompanies her. In order to obtain admission information from the client, what should the nurse do?

  • A. Add the client's daughter to serve as an interpreter.
  • B. Ask one of the Hispanic nursing assistants to serve as an interpreter.
  • C. Use the limited Spanish learned in high school along with nonverbal communication.
  • D. Obtain a trained medical interpreter.
Correct Answer: D

Rationale: A trained medical interpreter is required to ensure safety, accuracy of history data, and client confidentiality. The medical interpreter knows the client's rights and is familiar with the client's culture. Using the family member as interpreter violates the client's confidentiality. Using the nursing assistant or limited Spanish and nonverbal communication reduces the accuracy of interpretation and back-translation into English.

Which is an intrinsic risk factor that places the client at risk for pressure ulcers?

  • A. Pressure
  • B. Shearing
  • C. Impaired tissue perfusion
  • D. Friction
Correct Answer: C

Rationale: Impaired tissue perfusion is an intrinsic risk factor for pressure ulcers, as it reduces oxygen and nutrient delivery to tissues, increasing susceptibility to breakdown.

The nurse is caring for a client who has just returned to the nursing unit after an intravenous pyelogram (IVP). Which of the following nursing interventions is most appropriate at this time?

  • A. Encourage a large fluid intake.
  • B. Assess for return of bowel sounds.
  • C. Assist with morning care.
  • D. Administer a laxative as ordered.
Correct Answer: A

Rationale: Encouraging a large fluid intake post-IVP helps flush the contrast dye from the kidneys, reducing the risk of nephrotoxicity.

A client has primary health care provider instructions to take ibuprofen 0.4 g for mild pain. The medication bottle contains ibuprofen 200-mg tablets. How many tablets will the nurse instruct the client to take for each dose? Fill in the blank. tablets

Correct Answer: 2

Rationale: To determine the number of tablets, divide the prescribed dose by the strength per tablet: 0.4 g = 400 mg; 400 mg ÷ 200 mg per tablet = 2 tablets. Therefore, the nurse instructs the client to take 2 tablets per dose.

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