NCLEX RN Practice Test

A sudden increase in the amount of bleeding or passing large blood clots can indicate a post-partum hemorrhage, which is a serious complication requiring immediate medical attention. While it's common to have moderate bleeding and occasional small clots in the post-partum period, significant changes in volume or size of clots are not normal. Fever suggests infection, but it is not specific to abnormal bleeding. Mild cramping is expected as the uterus contracts, and slight pain during breastfeeding is a normal response to oxytocin release.

The correct action is to contact the prescribing health care provider to clarify the order. When there is a discrepancy between the prescribed dose and the available dose, it is the nurse's duty to ensure the accuracy and safety of the medication order before administering it. Administering the available dose of 50 mg without clarification can lead to overdosing and harm to the patient. Adjusting the dose independently without consulting the provider violates medication safety protocols and scope of practice. Withholding the medication and notifying the pharmacy about availability does not address the root issue of clarifying the provider's intent.

Using appropriate facial protection is essential in droplet precautions because respiratory droplets, which can carry pathogens, are the primary mode of transmission. Protective barriers like masks stop the spread from respiratory secretions when in proximity to the client. Gloves are helpful for preventing direct contact transmission but are insufficient for managing droplet-borne infections. Gowns and shields protect against contamination and splashes, but they do not provide the primary protection needed to block respiratory droplets.

The correct answer is appropriate because folic acid is critical for the prevention of neural tube defects such as spina bifida and anencephaly, which occur in the early weeks of pregnancy. Pregnant clients are advised to consume foods rich in folic acid (e.g., leafy greens, fortified cereals) or take prenatal vitamins containing at least 400-800 micrograms of folic acid daily. While protein is essential for fetal growth, and avoiding unpasteurized dairy products and raw fish reduces the risk of foodborne illnesses, these are not as critical at this stage as folic acid intake. Calorie increases should be modest in the first trimester.

The correct answer is to document the findings and report suspected abuse to the appropriate authorities. Nurses are mandated reporters and must act to protect client safety by escalating any concerns about abuse. Proper documentation ensures a clear record for legal and investigative purposes, while reporting initiates the process to safeguard the client.

Other answers, such as probing for more detailed explanations, may inadvertently compromise the investigation or cause further distress to the client. Offering reassurances or delaying action overlooks the priority of client safety and does not fulfill the nurse’s legal obligation to report suspected abuse.

The best initial action is to relieve pressure from the affected area by repositioning the client. Pressure relief and redistribution are critical in preventing pressure injuries from progressing. While applying a barrier cream or performing a detailed wound assessment are important steps, they do not address the primary cause of skin breakdown—prolonged pressure. Using wound dressing is more appropriate if the skin is already broken, which is not indicated in this scenario.

Ensuring the client gives informed consent is essential as it is a legal and ethical requirement before any surgical procedure. This step confirms that the client understands the nature, risks, and benefits of the procedure and agrees to it voluntarily. While completing a thorough preoperative checklist and gathering lab results are necessary, they are secondary to informed consent, which is a prerequisite for proceeding with surgery. Administering prescribed medications typically occurs closer to the procedure and must not precede verification of informed consent.

The correct answer is 10 mL. To determine the correct volume, the nurse should use a standard dosage calculation formula, such as 'Desired over Have' or dimensional analysis.

Using the formula (Desired Dose / Dose on Hand) x Quantity = Volume to Administer:

• Desired Dose: 200 mg
• Dose on Hand: 100 mg
• Quantity: 5 mL
• Calculation: (200 mg / 100 mg) x 5 mL = 2 x 5 mL = 10 mL.

An answer of 5 mL would be an underdose, as it only provides 100 mg of ibuprofen. An answer of 2.5 mL or 15 mL would indicate a calculation error, leading to an incorrect and potentially harmful dose.

The correct answer is to recommend a referral to a registered dietitian because a dietitian has specialized knowledge to create an individualized dietary plan for clients with diabetes. This ensures the client's nutritional needs are addressed by an expert in this area. Other options, such as contacting a social worker, providing general pamphlets, or instructing on advanced carbohydrate counting, may not fully address the client’s immediate need of meal planning assistance. While these options could be helpful at later stages of care, they do not substitute the expertise of a dietitian for this initial need.

Asking the nursing assistants to discuss the issue privately in a separate area helps de-escalate the immediate situation without further disrupting the care environment. This approach demonstrates professionalism, respects the privacy of all parties involved, and creates an opportunity for conflict resolution in a controlled setting. Reporting the incident to human resources without prior intervention may escalate the situation unnecessarily. Allowing the argument to continue without addressing it fails to uphold professional standards, and confronting the nursing assistants publicly can further damage working relationships and the work environment.

The correct answer is to assess the client's dietary intake because identifying what the client is eating provides critical information about their nutritional habits, caloric intake, and potential deficiencies. By understanding their intake, the nurse can determine if the weight loss is due to inadequate nutrition or another underlying issue. Other options, such as monitoring weight changes, can offer supportive data but fail to directly assess and address the root cause. Referring the client to a specialist without initial assessment delays interventions that could be managed at the primary level if the cause is dietary.

Arranging for a professional interpreter is the best action because interpreters trained in healthcare communication can accurately convey medical terminology and ensure understanding between the client and the care provider. While asking a family member may seem convenient, it can lead to miscommunication and privacy concerns. Written materials can support communication but are not a comprehensive solution to ensure the client's full understanding. Similarly, relying on nonverbal gestures limits the ability to clarify complex or detailed medical information.

At 9 months, infants are typically able to pull themselves to a standing position, one of the gross motor developmental milestones. It shows the child has achieved muscle strength, coordination, and development appropriate for their age. Smiling back at caregivers is a normal social milestone seen as early as 6-8 weeks, not specific to 9 months. Rolling over from back to front is typically expected by 6 months. Saying simple single words, such as 'mama' or 'dada,' may occur around 12 months, but this milestone is not expected by 9 months. Therefore, 'pulling to a standing position' is the correct answer.

The correct answer points to systematically developed recommendations that are updated with the latest research findings and provide reliable, evidence-based options for preventive care. While facility manuals address institution-specific practices, they might not always reflect the most comprehensive or current standards in healthcare. Clinical experience is valuable but must be supplemented with verified evidence to ensure the highest standard of care. Consulting a specialist is an effective action for complex cases, but it is not the most efficient first step for general prevention planning.

The nurse must assess the client's apical pulse before administering digoxin as it can cause bradycardia. If the apical pulse is below 60 beats per minute in an adult, the medication should be withheld, and the healthcare provider should be notified. Monitoring blood pressure and respiratory rate are important but are not as directly linked to digoxin toxicity and its primary cardiovascular effects. Asking about chest pain may be relevant if there are other symptoms but is not part of routine pre-administration checks for this medication.

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.

Proper preparation of the testing site, such as cleansing the skin with an antiseptic solution, ensures that the blood sample is not contaminated with external substances like dirt or oils. Failure to adequately prepare the site can lead to inaccurate glucose readings. Other options such as excessive squeezing of the finger can affect the blood composition and provide falsely elevated or lowered results.

The correct answer is to acknowledge and address the non-verbal cues through therapeutic communication. Behaviors such as avoiding eye contact, wringing hands, and sighing deeply may indicate emotional distress, such as anxiety or fear. Using an open-ended question like 'You seem upset. Would you like to talk about how you're feeling?' gives the client an opportunity to express their emotions, helping the nurse better understand the client's needs. Offering printed educational materials or prematurely providing reassurance without first exploring their emotions may invalidate the client's feelings. Similarly, attempting to explore feelings while overly focusing on providing reassurance about the medical team does not directly address the observable signs of distress.

The correct action is to respect the client’s right to make decisions about their own care and document their refusal. This practice aligns with the principle of autonomy, a foundational element of the nurses’ code of ethics, which supports individuals' rights to make informed decisions about their health care. Informing the client about implications or attempting to convince them disregards their autonomy and may lead to coercive practices. Administering treatment without consent violates ethical and legal standards in nursing.

The statement about using over-the-counter corn removers indicates a need for further teaching. Products like these often contain salicylic acid, which can irritate or burn the skin, particularly for individuals with diabetes who may experience peripheral neuropathy (reduced sensation in the feet) and poor wound healing. Clients should be instructed to avoid self-treatment of foot issues and seek professional care for calluses or other concerns. Wearing comfortable, correctly fitted footwear and checking the feet regularly for cuts, blisters, or redness are critical for preventing injuries. Additionally, consulting a healthcare provider for sores that do not heal is essential for timely intervention and avoiding complications.