2016 Maternity Questions NCLEX 1-10

Let us try to answer Maternity Questions NCLEX and read the rationale later . . .
1. The nursing student is preparing to teach a prenatal class about fetal circulation. Which statement should be included in the teaching plan?

a) “One artery carries oxygenated blood from the placenta to the fetus.”
b) “Two arteries carry oxygenated blood from the placenta to the fetus.”
c) “Two arteries carry deoxygenated blood and waste products away from the fetus to the placenta.” d) “Two veins carry blood that is high in carbon dioxide and other waste products away from the fetus to the placenta.”

2. Maternity Questions NCLEX about a nursing student is assigned to care for a client in labor. The nursing instructor asks the student to describe fetal circulation, specifically the ductus venosus. Which statement is correct regarding the ductus venosus?

a) Connects the pulmonary artery to the aorta
b) Is an opening between the right and left atria
c) Connects the umbilical vein to the inferior vena cava
d) Connects the umbilical artery to the inferior vena cava

3. A pregnant client tells the clinic nurse that she wants to know the gender of her baby as soon as it can be determined. The nurse understands that the client should be able to find out the gender at 12 weeks’ gestation because of which factor?

a) The appearance of the fetal external genitalia
b) The beginning of differentiation in the fetal groin
c) The fetal testes are descended into the scrotal sac
d) The internal differences in males and females become apparent

4. Maternity Questions NCLEX about the nurse who is performing an assessment on a client who is at 38 weeks’ gestation and notes that the fetal heart rate is 174 beats/minute. On the basis of this finding, what is the priority nursing action?

a) Document the finding.
b) Check the mother’s heart rate.
c) Notify the health care provider (HCP).
d) Tell the client that the fetal heart rate is normal.

5. The nurse is conducting a prenatal class on the female reproductive system. When a client in the class asks why the fertilized ovum stays in the fallopian tube for 3 days, what is the nurse’s best response?

a) “It promotes the fertilized ovum’s chances of survival.”
b) “It promotes the fertilized ovum’s exposure to estrogen and progesterone.”
c) “It promotes the fertilized ovum’s normal implantation in the top portion of the uterus.”
d) “It promotes the fertilized ovum’s exposure to luteinizing hormone and follicle-stimulating hormone.”

6. Maternity Questions NCLEX about the nursing instructor who asks a nursing student to list the characteristics of the amniotic fluid. The student responds correctly by listing which as characteristics of amniotic fluid? Select all that apply.

a) Allows for fetal movement
b) Surrounds, cushions, and protects the fetus
c) Maintains the body temperature of the fetus
d) Can be used to measure fetal kidney function
e) Prevents large particles such as bacteria from passing to the fetus
f) Provides an exchange of nutrients and waste products between the mother and the fetus

7. A couple comes to the family planning clinic and asks about sterilization procedures. Which question by the nurse would determine whether this method of family planning would be most appropriate?

a) “Has either of you ever had surgery?”
b) “Do you plan to have any other children?”
c) “Do either of you have diabetes mellitus?”
d) “Do either of you have problems with high blood pressure?”

8. The nurse should include which statement to a pregnant client found to have a gynecoid pelvis?

a) “Your type of pelvis has a narrow pubic arch.”
b) “Your type of pelvis is the most favorable for labor and birth.”
c) “Your type of pelvis is a wide pelvis, but has a short diameter.”
d) “You will need a cesarean section because this type of pelvis is not favorable for a vaginal delivery.”

9. Which explanation should the nurse provide to the prenatal client about the purpose of the placenta?

a) It cushions and protects the baby.
b) It maintains the temperature of the baby.
c) It is the way the baby gets food and oxygen.
d) It prevents all antibodies and viruses from passing to the baby.

10. Maternity Questions NCLEX about a 55-year-old male client who confides in the nurse that he is concerned about his sexual function. What is the nurse’s best response?

a) “How often do you have sexual relations?”
b) “Please share with me more about your concerns.”
c) “You are still young and have nothing to be concerned about.”
d) “You should not have a decline in testosterone until you are in your 80s.”




Maternity Questions NCLEX
Answers and Rationale

1) C
- Rationale: Blood pumped by the embryo’s heart leaves the embryo through two umbilical arteries. When oxygenated, the blood is returned by one umbilical vein. Arteries carry deoxygenated blood and waste products from the fetus, and the umbilical vein carries oxygenated blood and provides oxygen and nutrients to the fetus.

- Test-Taking Strategy: Focus on the subject , fetal circulation. Recall that three umbilical vessels are within the umbilical cord (two arteries and one vein) and that the vein carries oxygenated blood and the arteries carry deoxygenated blood.

2) C
- Maternity Questions NCLEX Rationale: The ductus venosus connects the umbilical vein to the inferior vena cava. The foramen ovale is a temporary opening between the right and left atria. The ductus arteriosus joins the aorta and the pulmonary artery.

- Test-Taking Strategy: Focus on the subject , the description of the ductus venosus. Note the relationship of the word venosus in the question and vein in the correct option.

3) A
- Rationale: By the end of the twelfth week, the external genitalia of the fetus have developed to such a degree that the gender of the fetus can be determined visually. Differentiation of the external genitalia occurs at the end of the ninth week. Testes descend into the scrotal sac at the end of the thirty-eighth week. Internal differences in the male and female occur at the end of the seventh week.

- Test-Taking Strategy: Focus on the subject, gender of the fetus. Remember that the gender of the fetus can be recognizable visually by the appearance of the external genitalia by gestational week 12.

4) C
- Maternity Questions NCLEX Rationale: The fetal heart rate (FHR) depends on gestational age and ranges from 160 to 170 beats/minute in the first trimester, but slows with fetal growth to 110 to 160 beats/minute near or at term. At or near term, if the FHR is less than 110 beats/minute or more than 160 beats/minute with the uterus at rest, the fetus may be in distress. Because the FHR is increased from the reference range, the nurse should notify the HCP. Options B and D are inappropriate actions based on the information in the question. Although the nurse documents the findings, based on the information in the question, the HCP needs to be notified.

- Test-Taking Strategy: Note the strategic word , “priority.” Also note the FHR and that the client is at 38 weeks of gestation. Remember that the normal FHR at or near term is 110 to 160 beats/minute.

5) C
- Rationale: The tubal isthmus remains contracted until 3 days after conception to allow the fertilized ovum to develop within the tube. This initial growth of the fertilized ovum promotes its normal implantation in the fundal portion of the uterine corpus. Estrogen is a hormone produced by the ovarian follicles, corpus luteum, adrenal cortex, and placenta during pregnancy. Progesterone is a hormone secreted by the corpus luteum of the ovary, adrenal glands, and placenta during pregnancy. Luteinizing hormone and follicle-stimulating hormone are excreted by the anterior pituitary gland. The survival of the fertilized ovum does not depend on it staying in the fallopian tube for 3 days.

- Maternity Questions NCLEX Test-Taking Strategy: Note the strategic word “best” and use knowledge of the anatomy and physiology of the female reproductive system. Remember that fertilization occurs in the fallopian tube and the fertilized ovum remains in the fallopian tube for about 3 days. This promotes its normal implantation.

6) A, B, C, D
- Rationale: The amniotic fluid surrounds, cushions, and protects the fetus. It allows the fetus to move freely and maintains the body temperature of the fetus. In addition, the amniotic fluid contains urine from the fetus and can be used to assess fetal kidney function. The placenta prevents large particles such as bacteria from passing to the fetus and provides an exchange of nutrients and waste products between the mother and the fetus.

- Maternity Questions NCLEX Test-Taking Strategy: Focus on the subject of the question: the characteristics of amniotic fluid. Visualizing the location of the amniotic fluid will assist in answering this question.

7) B
- Rationale: Sterilization is a method of contraception for couples who have completed their families. It should be considered a permanent end to fertility because reversal surgery is not always successful. The nurse would ask the couple about their plans for having children in the future. Options A, C, and D are unrelated to this procedure.

- Test-Taking Strategy: Note the strategic words , most appropriate. Focus on the subject , sterilization procedure. Noting the relationship between the word sterilization and the correct option will direct you to this option.

8) B
- Maternity Questions NCLEX Rationale: A gynecoid pelvis is a normal female pelvis and is the most favorable for successful labor and birth. An android pelvis (resembling a male pelvis) would be unfavorable for labor because of the narrow pelvic planes. An anthropoid pelvis has an outlet that is adequate, with a normal or moderately narrow pubic arch. A platypelloid pelvis (flat pelvis) has a wide transverse diameter, but the anteroposterior diameter is short, making the outlet inadequate.

- Test-Taking Strategy: Focus on the subject , female pelvis types. Recalling that the gynecoid pelvis is the normal female pelvis will direct you to the correct option.

9) C
- Rationale: The placenta provides an exchange of oxygen, nutrients, and waste products between the mother and the fetus. The amniotic fluid surrounds, cushions, and protects the fetus and maintains the body temperature of the fetus. Nutrients, drugs, antibodies, and viruses can pass through the placenta.

- Test-Taking Strategy: Focus on the subject , the purpose of the placenta. Remember that the placenta provides oxygen and nutrients.

10) B
- Maternity Questions NCLEX Rationale: The nurse needs to establish trust when discussing sexual relationships with men. Open the conversation with broad statements to determine the true nature of the client’s concerns. The frequency of intercourse is not a relevant first question to establish trust. Testosterone declines with the aging process.

- Test-Taking Strategy: Note the strategic word best. Determine whether further assessment or validation is needed. In this case, more information is needed to determine the nature of the client’s concerns. Keeping these concepts in mind and focusing on the subject will assist in directing you to the correct option.


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Maternity Questions NCLEX 11-20

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Latest Health Promotion NCLEX Questions 1-5

Let us begin answering Health Promotion NCLEX Questions now . . .
1. The clinic nurse is preparing to discuss the concepts of Kohlberg’s theory of moral development with a parent. What motivates good and bad actions for the child at the preconventional level?

a) Peer pressure
b) Social pressure
c) Parents’ behavior
d) Punishment and reward

2. The maternity nurse is providing instructions to a new mother regarding the psychosocial development of the newborn infant. Using Erikson’s psychosocial development theory, the nurse instructs the mother to take which measure?

a) Allow the newborn infant to signal a need.
b) Anticipate all the needs of the newborn infant.
c) Attend to the newborn infant immediately when crying.
d) Avoid the newborn infant during the first 10 minutes of crying.

3. Health Promotion NCLEX Questions about a mother of a 4-year-old child who calls the clinic nurse and expresses concern because the child has been masturbating. Using Freud’s psychosexual stages of development, the nurse should make which response?

a) “This is a normal behavior at this age.”
b) “Children usually begin this behavior at age 8 years.”
c) “The child is very young to begin this behavior and should be brought to the clinic.”
d) “This is not normal behavior, and the child should be seen by the health care provider.”

4. The nursing instructor asks a nursing student to present a clinical conference to peers regarding Freud’s psychosexual stages of development, specifically the anal stage. The student plans the conference, knowing that which characteristic relates to this stage of development?

a) This stage is associated with toilet training.
b) This stage is characterized by the gratification of self.
c) This stage is characterized by a tapering off of conscious biological and sexual urges.
d) This stage is associated with pleasurable and conflicting feelings about the genital organs.

5. The nursing instructor asks a nursing student to describe the formal operations stage of Piaget’s cognitive developmental theory. The correct response by the nursing student is which statement?

a) “The child has the ability to think abstractly.”
b) “The child begins to understand the environment.”
c) “The child is able to classify, order, and sort facts.”
d) “The child learns to think in terms of past, present, and future.”





Health Promotion NCLEX Questions
Answers and Rationale

1) D
- Rationale: In the preconventional stage, morals are thought to be motivated by punishment and reward. If the child is obedient and is not punished, then the child is being moral. The child sees actions as good or bad. If the child’s actions are good, the child is praised. If the child’s actions are bad, the child is punished. Options A, B, and C are incorrect for this stage of moral development.

- Test-Taking Strategy: Eliminate options A and B; they are comparable or alike because peer pressure is the same as social pressure. To select from the remaining options, recalling that the preconventional stage occurs between birth and 7 years will assist in directing you to the correct option.

2) A
- Health Promotion NCLEX Questions Rationale: According to Erikson, the caregiver should not try to anticipate the newborn infant’s needs at all times but must allow the newborn infant to signal needs. If a newborn infant is not allowed to signal a need, the newborn will not learn how to control the environment. Erikson believed that a delayed or prolonged response to a newborn infant’s signal would inhibit the development of trust and lead to mistrust of others.

- Test-Taking Strategy: Eliminate options B, C, and D because of the closed-ended words all, immediately, and avoid in these options.

3) A
- Rationale: According to Freud’s psychosexual stages of development, between the ages of 3 and 6 the child is in the phallic stage. At this time, the child devotes much energy to examining his or her genitalia, masturbating, and expressing interest in sexual concerns. Therefore options B, C, and D are incorrect.

- Test-Taking Strategy: Eliminate options C and D first because they are comparable or alike , indicating that the child’s behavior is abnormal. Next, focus on the subject , that a 4-year-old child is masturbating and note the words age 8 years in option B to assist in eliminating this option.

4) A
- Health Promotion NCLEX Questions Rationale: In general, toilet training occurs during the anal stage. According to Freud, the child gains pleasure from the elimination of feces and from their retention. Option B relates to the oral stage. Option C relates to the latency period. Option D relates to the phallic stage.

- Test-Taking Strategy: Focus on the subject , the anal stage. Note the relationship between the words anal in the question and toilet training in the correct option.

5) A
- Rationale: In the formal operations stage, the child has the ability to think abstractly and logically. Option B identifies the sensorimotor stage. Option C identifies the concrete operational stage. Option D identifies the preoperational stage.

- Test-Taking Strategy: Focus on the subject , the formal operations stage of Piaget’s cognitive developmental theory, and note the relationship between the subject and the description in the correct option. Remember that in the formal operations stage, the child has the ability to think abstractly and logically.


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Health Promotion NCLEX Questions 6-10

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Compilation of NCLEX Practice Questions

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There are so many questions arrange in different set of topics to choose from. We recommend you to try and answer all exams below to be well-equipped for the NCLEX. These exams will enhance your critical thinking skills so that during the actual exam, questions will appear familiar. The first five questions in each category are listed below and links to the succeeding questions for the same topic will be provided at the end of each page. Read each question carefully and choose the best answer. Be sure to read the answers and rationale. You can send your clarification to us through the provided comment section below.

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Med Surg NCLEX Review Questions 1-5

Your Med Surg NCLEX Review Questions starts now...

1. The nurse has just reassessed the condition of a postoperative client who was admitted 1 hour ago to the surgical unit. The nurse plans to monitor which parameter most carefully during the next hour?

a) Urinary output of 20 mL/hour
b) Temperature of 37.6 ° C (99.6 ° F)
c) Blood pressure of 100/70 mm Hg
d) Serous drainage on the surgical dressing

2. A postoperative client asks the nurse why it is so important to deep-breathe and cough after surgery. When formulating a response, the nurse incorporates the understanding that retained pulmonary secretions in a postoperative client can lead to which condition?

a) Pneumonia
b) Hypoxemia
c) Fluid imbalance
d) Pulmonary embolism

3. The nurse is developing a plan of care for a client scheduled for surgery. The nurse should include which activity in the nursing care plan for the client on the day of surgery?

a) Avoid oral hygiene and rinsing with mouthwash.
b) Verify that the client has not eaten for the last 24 hours.
c) Have the client void immediately before going into surgery.
d) Report immediately any slight increase in blood pressure or pulse.

4. A client with a perforated gastric ulcer is scheduled for surgery. The client cannot sign the operative consent form because of sedation from opioid analgesics that have been administered. The nurse should take which most appropriate action in the care of this client?

a) Obtain a court order for the surgery.
b) Have the charge nurse sign the informed consent immediately.
c) Send the client to surgery without the consent form being signed.
d) Obtain a telephone consent from a family member, following agency policy.

5. A preoperative client expresses anxiety to the nurse about upcoming surgery. Which response by the nurse is most likely to stimulate further discussion between the client and the nurse?

a) “If it’s any help, everyone is nervous before surgery.”
b) “I will be happy to explain the entire surgical procedure to you.”
c) “Can you share with me what you’ve been told about your surgery?”
d) “Let me tell you about the care you’ll receive after surgery and the amount of pain you can anticipate.”





Med Surg NCLEX Review Questions
Answers and Rationale

1) A
- Rationale: Urine output should be maintained at a minimum of 30 mL/hour for an adult. An output of less than 30 mL for each of 2 consecutive hours should be reported to the health care provider. A temperature higher than 37.7 ° C (100 ° F) or lower than 36.1 ° C (97 ° F) and a falling systolic blood pressure, lower than 90 mm Hg, are usually considered reportable immediately. The client’s preoperative or baseline blood pressure is used to make informed postoperative comparisons. Moderate or light serous drainage from the surgical site is considered normal.

- Test-Taking Strategy: Note the strategic word most. Focus on the subject , expected postoperative assessment findings. To answer this question correctly, you must know the normal ranges for temperature, blood pressure, urinary output, and wound drainage. Note that the urinary output is the only observation that is not within the normal range.

2) A
- Rationale: Postoperative respiratory problems are atelectasis, pneumonia, and pulmonary emboli. Pneumonia is the inflammation of lung tissue that causes productive cough, dyspnea, and lung crackles and can be caused by retained pulmonary secretions. Hypoxemia is an inadequate concentration of oxygen in arterial blood. Fluid imbalance can be a deficit or excess related to fluid loss or overload. Pulmonary embolus occurs as a result of a blockage of the pulmonary artery that disrupts blood flow to one or more lobes of the lung; this is usually due to clot formation.

- Test-Taking Strategy: Focus on the subject , a postoperative complication caused by retained pulmonary secretions. Focus on the relationship between the words deep-breathe and cough in the question and pneumonia.

3) C
- Rationale: The nurse would assist the client to void immediately before surgery so that the bladder will be empty. Oral hygiene is allowed, but the client should not swallow any water. The client usually has a restriction of food and fluids for 6 to 8 hours before surgery instead of 24 hours. A slight increase in blood pressure and pulse is common during the preoperative period and is usually the result of anxiety.

- Test-Taking Strategy: Focus on the subject , preoperative care measures. Think about the measures that may be helpful and promote comfort. Oral hygiene should be administered since it may make the client feel more comfortable. A client should be NPO for 6 to 8 hours before surgery rather than 24 hours. A slight increase in blood pressure or pulse is insignificant in this situation.

4) D
- Rationale: Every effort should be made to obtain permission from a responsible family member to perform surgery if the client is unable to sign the consent form. A telephone consent must be witnessed by two persons who hear the family member’s oral consent. The two witnesses then sign the consent with the name of the family member, noting that an oral consent was obtained. Consent is not informed if it is obtained from a client who is confused, unconscious, mentally incompetent, or under the influence of sedatives. In an emergency, a client may be unable to sign and family members may not be available. In this situation, a health care provider is permitted legally to perform surgery without consent, but in this case it is not an emergency. Options A and C are not appropriate in this situation. Also, agency policies regarding informed consent should always be followed.

- Test-Taking Strategy: Note the strategic words most appropriate. Focus on the data in the question. Eliminate A and C first. Option A will delay necessary surgery and option C is inappropriate. Select the correct option over option B because it is the most appropriate of the options presented and it is legally acceptable to obtain a telephone permission from a family member if it is witnessed by two persons.

5) C
- Rationale: Explanations should begin with the information that the client knows. By providing the client with individualized explanations of care and procedures, the nurse can assist the client in handling anxiety and fear for a smooth preoperative experience. Clients who are calm and emotionally prepared for surgery withstand anesthesia better and experience fewer postoperative complications. Option A does not focus on the client’s anxiety. Explaining the entire surgical procedure may increase the client’s anxiety. Option D avoids the client’s anxiety and is focuses on postoperative care.

- Test-Taking Strategy: Note that the client expresses anxiety. Use knowledge of therapeutic communication techniques . Note that the question contains the strategic words most likely and also note the words stimulate further discussion . Also use the steps of the nursing process . The correct option addresses assessment and is the only therapeutic response.



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Med Surg NCLEX Review Questions 6-10

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2016 NCLEX Practice Questions on Blood Infusion 81-85

81. A client is brought to the emergency department having experienced blood loss related to an arterial laceration. Fresh-frozen plasma is prescribed and transfused to replace fluid and blood loss. The nurse understands that which is the rationale for transfusing fresh-frozen plasma to this client?

a) To treat the loss of platelets
b) To promote rapid volume expansion
c) Because a transfusion must be done slowly
d) Because it will increase the hemoglobin and hematocrit levels

82. The nurse who is about to begin a blood transfusion knows that blood cells start to deteriorate after a certain period of time. Which item is important to check regarding the age of blood cells before the transfusion is begun?

a) Expiration date
b) Presence of clots
c) Blood group and type
d) Blood identification number

83. A client requiring surgery is anxious about the possible need for a blood transfusion during or after the procedure. The nurse suggests to the client to take which action(s) to reduce the risk of possible transfusion complications? Select all that apply.

a) Ask a family member to donate blood ahead of time.
b) Give an autologous blood donation before the surgery.
c) Take iron supplements before surgery to boost hemoglobin levels.
d) Request that any donated blood be screened twice by the blood bank.
e) Take adequate amounts of vitamin C several days prior to the surgery date.

84. A client with severe blood loss resulting from multiple trauma requires rapid transfusion of several units of blood. The nurse asks another health team member to obtain which device for use during the transfusion procedure to help reduce the risk of cardiac dysrhythmias?

a) Infusion pump
b) Pulse oximeter
c) Cardiac monitor
d) Blood-warming device

85. A client has a prescription to receive a unit of packed red blood cells. The nurse should obtain which intravenous (IV) solution from the IV storage area to hang with the blood product at the client’s bedside?

1. Lactated Ringer’s
2. 0.9% sodium chloride
3. 5% dextrose in 0.9% sodium chloride
4. 5% dextrose in 0.45% sodium chloride





NCLEX Practice Questions
Answers and Rationale

81) B
- Rationale: Fresh-frozen plasma is often used for volume expansion as a result of fluid and blood loss. It does not contain platelets, so it is not used to treat any type of low platelet count disorder. It is rich in clotting factors and can be thawed quickly and transfused quickly. It will not specifically increase the hemoglobin and hematocrit level.

- Test-Taking Strategy: Focus on the subject of the question, the purpose for transfusing fresh frozen plasma. Note the relationship between the words experienced blood loss and the correct option.

82) A
- Rationale: The nurse notes the expiration date on the unit of blood to ensure that the blood is fresh. Blood cells begin to deteriorate over time, so safe storage usually is limited to 35 days. Careful notation of the expiration date by the nurse is an essential part of the verification process before hanging a unit of blood. The nurse also notes the blood identification (unit) number, blood group and type, and client’s name. The nurse also inspects the unit of blood for leaks, abnormal color, clots, and bubbles and returns the unit to the blood bank if clots are noted.

Test-Taking Strategy: Focus on the subject , measures to verify prior to blood administration. Note the word deteriorate . To answer this question correctly, you must know which part of the pretransfusion verification procedure relates to the freshness of the unit of blood. Keeping this in mind should direct you to the correct option.

83) A, B
- Rationale: A donation of the client’s own blood before a scheduled procedure is autologous. Donating autologous blood to be reinfused as needed during or after surgery reduces the risk of disease transmission and potential transfusion complications. The next most effective way is to ask a family member to donate blood before surgery. Blood banks do not provide extra screening on request. Preoperative iron supplements are helpful for iron deficiency anemia but are not helpful in replacing blood lost during the surgery. Vitamin C enhances iron absorption, but also is not helpful in replacing blood lost during surgery.

- Test-Taking Strategy: Focus on the subject , reducing the risk of possible transfusion complications. Recalling that an autologous transfusion is the collection of the client’s own blood and also that family donation of blood is usually effective will direct you to the correct options.

84) D
- Rationale: If several units of blood are to be administered, a blood warmer should be used. Rapid transfusion of cool blood places the client at risk for cardiac dysrhythmias. To prevent this, the nurse warms the blood with a blood-warming device. Pulse oximetry and cardiac monitoring equipment are useful for the early assessment of complications but do not reduce the occurrence of cardiac dysrhythmias. Electronic infusion devices are not helpful in this case because the infusion must be rapid, and infusion devices generally are used to control the flow rate. In addition, not all infusion devices are made to handle blood or blood products.

- Test-Taking Strategy: Note the words rapid and reduce the risk . These words tell you that the infusions will infuse quickly and that the correct option is the one that will minimize the risk of cardiac dysrhythmias. Eliminate the pulse oximeter and cardiac monitor first because these items are comparable or alike and are used to assess for rather than reduce the risk of complications. From the remaining options, use knowledge related to the complications of transfusion therapy and note the relationship between the words several units of blood in the question and blood-warming device in the correct option.

85) B
- Rationale: Sodium chloride 0.9% (normal saline) is a standard isotonic solution used to precede and follow infusion of blood products. Dextrose is not used because it could result in clumping and subsequent hemolysis of red blood cells. Lactated Ringer’s is not the solution of choice with this procedure.

- Test-Taking Strategy: Eliminate options that contain dextrose first because they are comparable or alike . From the remaining options, remember that normal saline is an isotonic solution and the solution compatible with red blood cells.


Beginning of NCLEX Practice Questions about Fundamentals of Nursing here ...

Parenteral Nutrition NCLEX Questions (Fundamentals 76-80)

76. The nurse is preparing to hang the first bag of parenteral nutrition (PN) solution via the central line of an assigned client. The nurse should obtain which most essential piece of equipment before hanging the solution?
a) Urine test strips
b) Blood glucose meter
c) Electronic infusion pump
d) Noninvasive blood pressure monitor

77. The nurse is making initial rounds at the beginning of the shift and notes that the parenteral nutrition (PN) bag of an assigned client is empty. Which solution readily available on the nursing unit should the nurse hang until another PN solution is mixed and delivered to the nursing unit?

a) 5% dextrose in water
b) 10% dextrose in water
c) 5% dextrose in Ringer’s lactate
d) 5% dextrose in 0.9% sodium chloride

78. The nurse is monitoring the status of a client’s fat emulsion (lipid) infusion and notes that the infusion is 1 hour behind. Which action should the nurse take?

a) Adjust the infusion rate to catch up over the next hour.
b) Increase the infusion rate to catch up over the next 2 hours.
c) Ensure that the fat emulsion infusion rate is infusing at the prescribed rate.
d) Adjust the infusion rate to run wide open until the solution is back on time.

79. A client receiving parenteral nutrition (PN) in the home setting has a weight gain of 5 lb in 1 week. The nurse should next assess the client for the presence of which condition?

a) Thirst
b) Polyuria
c) Decreased blood pressure
d) Crackles on auscultation of the lungs

80. The nurse is caring for a restless client who is beginning nutritional therapy with parenteral nutrition (PN). The nurse should plan to ensure that which action is taken to prevent the client from sustaining injury?

a) Calculate daily intake and output.
b) Monitor the temperature once daily.
c) Secure all connections in the PN system.
d) Monitor blood glucose levels every 12 hours.

81. A client receiving parenteral nutrition (PN) complains of a headache. The nurse notes that the client has an increased blood pressure, bounding pulse, jugular vein distention, and crackles bilaterally. The nurse determines that the client is experiencing which complication of PN therapy?

a) Sepsis
b) Air embolism
c) Hypervolemia
d) Hyperglycemia




Answers and Rationale

 76) C
- The nurse obtains an electronic infusion pump before hanging a PN solution. Because of the high glucose content, use of an infusion pump is necessary to ensure that the solution does not infuse too rapidly or fall behind. Because the client’s blood glucose level is monitored every 4 to 6 hours during administration of PN, a blood glucose meter also will be needed, but this is not the most essential item needed before hanging the solution. Urine test strips (to measure glucose) rarely are used because of the advent of blood glucose monitoring. Although the blood pressure will be monitored, a noninvasive blood pressure monitor is not the most essential piece of equipment needed for this procedure.

77) B
- The client is at risk for hypoglycemia; therefore the solution containing the highest amount of glucose should be hung until the new PN solution becomes available. Because PN solutions contain high glucose concentrations, the 10% dextrose in water solution is the best of the choices presented. The solution selected should be one that minimizes the risk of hypoglycemia. The remaining options will not be as effective in minimizing the risk of hypoglycemia.

78) C
- The nurse should not increase the rate of a fat emulsion to make up the difference if the infusion timing falls behind. Doing so could place the client at risk for fat overload. In addition, increasing the rate suddenly can cause fluid overload. The same principle (not increasing the rate) applies to PN or any intravenous (IV) infusion. Therefore the remaining options are incorrect.

79) D
- Optimal weight gain when the client is receiving PN is 1 to 2 lb/week. The client who has a weight gain of 5 lb/week while receiving PN is likely to have fluid retention. This can result in hypervolemia. Signs of hypervolemia include increased blood pressure, crackles on lung auscultation, a bounding pulse, jugular vein distention, headache, and weight gain more than desired. Thirst and polyuria are associated with hyperglycemia. A decreased blood pressure is likely to be noted in deficient fluid volume.

80) C
- The nurse should plan to secure all connections in the tubing (tape is used per agency protocol). This helps prevent the restless client from pulling the connections apart accidentally. The nurse should also monitor intake and output, but this does not relate specifically to a risk for injury as presented in the question. Also, monitoring the temperature and blood glucose levels does not relate to a risk for injury as presented in the question. In addition, the client’s temperature and blood glucose levels are monitored more frequently than the time frames identified in the options to detect signs of infection and hyperglycemia, respectively.

81) C
- Hypervolemia is a critical situation and occurs from excessive fluid administration or administration of fluid too rapidly. Clients with cardiac, renal, or hepatic dysfunction are also at increased risk. The client’s signs and symptoms presented in the question are consistent with hypervolemia. The increased intravascular volume increases the blood pressure, whereas the pulse rate increases as the heart tries to pump the extra fluid volume. The increased volume also causes neck vein distention and shifting of fluid into the alveoli, resulting in lung crackles. The signs and symptoms presented in the question do not indicate sepsis, air embolism, or hyperglycemia.


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Parenteral Nutrition NCLEX Questions (Fundamentals 81-85)

Fluid and Electrolytes NCLEX Questions (81-85)

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81. The nurse reviews the arterial blood gas results of a client and notes the following: pH 7.45, Pco 2 of 30 mm Hg, and of 20 mEq/L. The nurse analyzes these results as indicating which condition?

a) Metabolic acidosis, compensated
b) Respiratory alkalosis, compensated
c) Metabolic alkalosis, uncompensated
d) Respiratory acidosis, uncompensated

82. The nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client, knowing that the client is at risk for which acid-base disorder?

a) Metabolic acidosis
b) Metabolic alkalosis
c) Respiratory acidosis
d) Respiratory alkalosis

83. A client with a 3-day history of nausea and vomiting presents to the emergency department. The client is hypoventilating and has a respiratory rate of 10 breaths/minute. The electrocardiogram (ECG) monitor displays tachycardia, with a heart rate of 120 beats/minute. Arterial blood gases are drawn and the nurse reviews the results, expecting to note which finding?

a) A decreased pH and an increased CO 2
b) An increased pH and a decreased CO 2
c) A decreased pH and a decreased
d) An increased pH with an increased

84. The nurse caring for a client with an ileostomy understands that the client is most at risk for developing which acid-base disorder?

a) Metabolic acidosis
b) Metabolic alkalosis
c) Respiratory acidosis
d) Respiratory alkalosis

85. The nurse is caring for a client with diabetic ketoacidosis and documents that the client is experiencing Kussmaul’s respirations. On the basis of this documentation, which pattern did the nurse observe?

a) Respirations that cease for several seconds
b) Respirations that are regular but abnormally slow
c) Respirations that are labored and increased in depth and rate
d) Respirations that are abnormally deep, regular, and increased in rate



Fluid and Electrolytes NCLEX Questions
Answers and Rationale

81) B
- The normal pH is 7.35 to 7.45. In a respiratory condition, an opposite effect will be seen between the pH and the Pco 2 . In this situation, the pH is at the high end of the normal value and the Pco 2 is low. In an alkalotic condition, the pH is elevated. Therefore the values identified in the question indicate a respiratory alkalosis that is compensated by the kidneys through the renal excretion of bicarbonate. Because the pH has returned to a normal value, compensation has occurred.

82) B
- Metabolic alkalosis is defined as a deficit or loss of hydrogen ions or acids or an excess of base (bicarbonate) that results from the accumulation of base or from a loss of acid without a comparable loss of base in the body fluids. This occurs in conditions resulting in hypovolemia, the loss of gastric fluid, excessive bicarbonate intake, the massive transfusion of whole blood, and hyperaldosteronism. Loss of gastric fluid via nasogastric suction or vomiting causes metabolic alkalosis as a result of the loss of hydrochloric acid. The remaining options are incorrect interpretations.

 83) D
- Clients experiencing nausea and vomiting would most likely present with metabolic alkalosis resulting from loss of gastric acid, thus causing the pH and to increase. Symptoms experienced by the client would include hypoventilation and tachycardia. Option A reflects a respiratory acidotic condition. Option B reflects a respiratory alkalotic condition, and option C reflects a metabolic acidotic condition.

84) A
- Metabolic acidosis is defined as a total concentration of buffer base that is lower than normal, with a relative increase in the hydrogen ion concentration. This results from loss of buffer bases or retention of too many acids without sufficient bases, and occurs in conditions such as kidney disease; diabetic ketoacidosis; high fat diet; insufficient metabolism of carbohydrates; malnutrition; ingestion of toxins, such as acetylsalicylic acid (aspirin); malnutrition; or severe diarrhea. Intestinal secretions are high in bicarbonate and may be lost through enteric drainage tubes, an ileostomy, or diarrhea. These conditions result in metabolic acidosis. The remaining options are incorrect interpretations and are not associated with the client with an ileostomy.

 85) D
- Kussmaul’s respirations are abnormally deep, regular, and increased in rate. Apnea is described as respirations that cease for several seconds. In bradypnea, respirations are regular but abnormally slow. In hyperpnea, respirations are labored and increased in depth and rate.


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Fluid and Electrolytes NCLEX Questions (1-6)


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Respiratory NCLEX Questions with Rationale 1-9