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NCLEX National Council Licensure Examination(NCLEX-RN) Sample Questions (Q332-Q337):

NEW QUESTION # 332
The client has been in active labor for the last 12 hours. During the last 3 hours, labor has been augmented with oxytocin because of hypoactive uterine contractions. Her physician assesses her cervix as 95% effaced, 8 cm dilated, and the fetus is at 0 station. Her oral temperature is 100.2F at this time. The physician orders that she be prepared for a cesarean delivery. In preparing the client for the cesarean delivery, which one of the following physician's orders should the RN question?

  • A. Discontinue the oxytocin infusion.
  • B. Prepare abdominal area from below the nipples to below the symphysis pubis area.
  • C. Administer meperidine (Demerol) 100 mg IM 1 hour prior to the delivery.
  • D. Insert an indwelling Foley catheter prior to delivery.

Answer: C

Explanation:
Explanation
(A) Meperidine is a narcotic analgesic medication that crosses the placental barrier and reaches the fetus, causing respiratory depression in the fetus. A narcotic medication should never be included in the preoperative order for a cesarean delivery. (B) Oxytocin infusion would be discontinued if client is being prepared for a cesarean delivery because the medication would not be needed. (C) The bladder is always emptied prior to and during the surgical intervention to prevent the urinary bladder from accidentally being incised while the uterine incision is made. (D) The abdominal area is always prepared to rid the area of hair before the abdominal incision is made. Abdominal hair cannot be sterilized and could become a source for postoperative incisional infection.


NEW QUESTION # 333
When inspecting a cardiovascular client, the nurse notes that he needs to sit upright to breathe. This behavior is most indicative of:

  • A. Pericarditis
  • B. Congestive heart failure
  • C. Anxiety
  • D. Angina

Answer: B

Explanation:
(A) Pericarditis can cause dyspnea but primarily causes chest pain. (B) Anxiety can cause dyspnea resulting in SOB, yet it is not typically influenced by degree of head elevation. (C) The inability to oxygenate well without being upright is most indicative of congestive heart failure, due to alveolar drowning. (D) Angina causes primarily chest pain; any SOB associated with angina is not influenced by body position.


NEW QUESTION # 334
The nurse will be alert to the most potentially lifethreatening side effect associated with the administration of monoamine oxidase (MAO) inhibitor. This is:

  • A. Orthostatic hypotension
  • B. Oculogyric crisis
  • C. Hypertensive crisis
  • D. Tardive dyskinesia

Answer: C

Explanation:
(A) Oculogyric crisis, involuntary upward deviation and fixation of the eyeballs, is usually associated with either postencephalitic parkinsonian or drug-induced extrapyramidal symptoms (EPS). (B) Hypertensive crisis is a potentially life-threatening side effect. This may occur if the client ingests foods, beverages, or medications containing tyramine. (C) Orthostatic hypotension, a drop in blood pressure resulting from a rapid change of body position, can occur with the administration of antidepressants. (D) Tardive dyskinesia, characterized by slow, rhythmical, automatic or stereotyped muscular movements, usually is associated with the administration of certain antipsychotic medications.


NEW QUESTION # 335
Following TURP, which of the following instructions would be appropriate to prevent or alleviate anxiety concerning the client's sexual functioning?

  • A. "Many men experience impotence following TURP."
  • B. "Check with your doctor about resuming sexual activity."
  • C. "A transurethral resection does not usually cause impotence."
  • D. "You may resume sexual intercourse in 2 weeks."

Answer: C

Explanation:
Explanation/Reference:
Explanation:
(A) Sexual activity should be delayed until cleared by the client's physician. (B) Although many men experience retrograde ejaculation following prostate surgery, potency is seldom affected. (C) Although the client may experience retrograde ejaculation, it will not limit his ability to engage in sexual intercourse. (D) Although the client should obtain clearance from his physician before resuming sexual activity, this statement does not give the client any information or reassurance about future sexual activity or potency that could decrease his anxiety.


NEW QUESTION # 336
A 52-year-old client's abdominal aortic aneurysm ruptured. She received rapid massive blood transfusions for bleeding. One potential complication of blood administration for which she is especially at risk is:

  • A. Hypokalemia
  • B. Hypocalcemia
  • C. Air embolus
  • D. Circulatory overload

Answer: B

Explanation:
Explanation/Reference:
Explanation:
(A) Air embolism is a potential complication of blood administration, but it is fairly rare and can be prevented by using good IV technique. (B) Circulatory overload is a potential complication of blood administration, but because this client is actively bleeding, she is not at high risk for overload. (C) Hypocalcemia is a potential complication of blood administration that occurs in situations where massive transfusion has occurred over a short period of time. It occurs because the citrate in stored blood binds with the client's calcium. Another potential complication for which this client is especially at risk is hypothermia, which can be prevented by using a blood warmer to administer the blood. (D) Hypokalemia is not a complication of blood administration.


NEW QUESTION # 337
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