NCLEX RN Practice Test

True. In the third trimester, lying on the back can compress the inferior vena cava, reducing blood return to the heart and decreasing cardiac output. This can cause supine hypotensive syndrome, where the mother may experience dizziness, and fetal oxygenation may decrease due to reduced uteroplacental blood flow. Educating clients to adopt side-lying positions helps optimize blood circulation and promote both maternal comfort and fetal health.

Heat therapy is an effective non-pharmacological measure for alleviating localized muscular pain, as it promotes muscle relaxation, increases blood flow, and decreases stiffness. However, it is important to assess for contraindications, such as impaired sensation or circulation issues, before applying heat. This ensures the intervention is safe and effective.

The correct answer is to confirm the client’s understanding of discharge instructions and provide additional resources. Confirming understanding ensures that the client knows how to manage their care at home, recognizes warning signs, and adheres to their medication or treatment regimen, reducing the risk of complications. Verifying that a caregiver is present or scheduling a follow-up appointment, while important, focuses on logistical aspects rather than direct client understanding, which is key for safety. Finalizing documentation is a required administrative action but does not directly prioritize client safety.

The correct answer focuses on involving a social worker to provide support and identify resources that can help the client manage their health while dealing with occupational and financial stressors. This approach is aligned with holistic care principles, ensuring the client has access to the support needed to balance work, family, and health responsibilities.

Other options might seem appropriate but do not directly address the root issue. For instance, offering relaxation techniques or lifestyle coaching could benefit the client long term but do not immediately help address the stress caused by their specific situation. Similarly, suggesting that the client reduce work commitments might not be realistic without a concrete plan or resources in place to support such a change.

Redirecting the client to a less stimulating environment is an appropriate behavioral management technique. It addresses the client's agitation by minimizing external triggers and providing a calm space, which promotes emotional regulation. Other interventions, such as restricting the client from leaving the group or attempting to discipline them, may escalate the situation and are not considered evidence-based strategies for managing agitation. Educating about behavior is important but is better suited for a moment when the client is calm and receptive.

The recommended daily calcium intake for adults 65 years and older is 1,200 mg to support bone health and reduce fracture risk. The value of 1,000 mg is appropriate for younger adults but insufficient for older adults, who have increased bone density loss. A recommendation of 1,500 mg may seem reasonable but is higher than necessary for most individuals unless prescribed for specific medical conditions. Too low an intake, such as 800 mg, fails to meet the body's requirements and could result in poor bone health. Nurses must advocate for accurate guidelines to ensure optimal calcium intake without unnecessary health risks.

Using an assistive device, such as a transfer belt, ensures that the nurse follows ergonomic principles, reducing the strain on their own body while providing safe and effective care to the client. This approach distributes the weight more evenly and provides the nurse with better control during client transfers. Manually lifting the client or failing to adjust the bed height can lead to significant back strain or injury. Rotating at the waist instead of using the legs can cause improper body mechanics and result in injury.

The correct answer is increasing ambulation, as it helps stimulate peristalsis and promotes natural bowel motility, which is often slowed after surgery. This is a first-line, non-invasive intervention that prioritizes the client's safety while addressing the issue effectively. Administering a laxative or offering an enema might be considered later if conservative measures like increased activity and hydration fail but are not initial steps. Managing oral fluid intake to avoid abdominal distension is incorrect because limiting fluids can exacerbate constipation rather than resolving it.

The correct answer is based on understanding that hypokalemia increases the risk of digoxin toxicity, which can result in serious complications such as cardiac arrhythmias. When serum potassium is low, the nurse must withhold the medication and notify the healthcare provider for further assessment and management. Elevated liver enzymes and hemoglobin level of 11.8 g/dL, while notable, do not directly contraindicate digoxin administration in this scenario. A heart rate of 82 bpm is within the normal range and does not require withholding the medication.

Applying the updated policy while caring for clients ensures current, evidence-based practices, which are essential for preventing HAIs and promoting client safety. Informing the health care team or consulting leadership may help spread awareness or clarify doubts but does not directly utilize the resource in care delivery. Ignoring updated policies jeopardizes patient health and safety.

Clients should always confirm their medication by reading the label to ensure they are taking the correct dose and medication prescribed. This reduces the risk of medication errors. Relying on memory or the physical appearance of medication can be misleading as medications may look similar in color or shape. Additionally, using an appropriate household tool, rather than specialized measuring tools, can lead to inaccurate dosing.

The correct answer is the one that reflects therapeutic communication techniques such as empathy, active listening, and validation of the client's feelings. Responses should avoid judgment, false reassurance, or dismissiveness. For example, reflecting on the client's emotions validates their experience, fosters a safe environment, and encourages further dialogue. Other responses may discourage the client from sharing or provide unhelpful feedback.

Encouraging consistent hand hygiene is essential for a school-age child because it significantly reduces the risk of infectious diseases, such as colds and gastrointestinal illnesses, which are common in school settings. While advising on proper nutrition and hydration is also important to the child's growth and learning, and discussing bullying prevention is relevant to emotional health, hand hygiene directly supports physical health and aligns closely with the parent's concern for the child's safety and health in this context. Other options, such as teaching traffic safety, relate more broadly to safety but are less closely tied to the immediate concern about the school environment.

Reporting suspected abuse to the Child Protection Agency (CPA) is the correct course of action for a healthcare professional who observes potential signs of abuse or neglect. Nurses are mandated reporters, meaning they are legally required to escalate suspected abuse to the appropriate authorities. Visible bruises at different stages of healing raise concerns of repeated harm, while the caregiver's defensive demeanor and vague explanations further indicate a need for investigation. Simply documenting findings or attempting to secure independent verification is insufficient, as it could delay intervention needed to protect the child. Providing injury prevention advice in this scenario is inappropriate, as it does not address the root concern of potential abuse.

The correct answer is an absence of a palpable pulse matching the pacemaker rate, as this indicates the pacemaker may not be effectively responding and capturing the heart's electrical activity. A pacemaker should generate electrical impulses that result in heart contractions, and this is confirmed by matching the pulse to the pacemaker's programmed rate.

Other options like mild redness at the insertion site may indicate normal inflammatory response or expected healing, but they don't require immediate intervention unless signs of infection are prominent. Similarly, complaints of fatigue shortly after implantation might occur due to the client's adjustment to the device, but it typically doesn't warrant immediate action unless symptoms are severe.