NCLEX NCLEX-PN Online Practice Questions and Exam Preparation

NCLEX NCLEX-PN Online Questions & Answers

• Question 961:

  You are preparing a sterile field for an operating room surgical procedure.

  When should you stop the preparation of this sterile field?

  A. When you have placed a sterile item only 1 inch and not 2 inches from the edge of the sterile field.
  B. When you have completely finished the field. You cannot stop the set up until it is all done.
  C. When you have accidentally poured a sterile liquid into a container that was on the sterile field.
  D. When you turn your upper body only away from the field because the surgeon calls your name.
  D. When you turn your upper body only away from the field because the surgeon calls your name.

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  You must stop the preparation of the sterile field and begin all over again when you have turned your upper body away from the field because sterile technique has been violated and the sterility of the field has been broken even when on turns away from the sterile field even for a second. Sterile items must be placed within one inch, not two inches from the edge of the sterile field. Lastly, sterile solutions can be poured into sterile containers on the sterile field without breaking the techniques required according to surgical asepsis.

• Question 962:

  A nurse observes a client sitting alone and talking. When asked, the client reports that he is "talking to the voices."

  The nurse's next action should be __________.

  A. touching the client to help him return to reality
  B. leaving the client alone until reality returns
  C. asking the client to describe what is happening
  D. telling the client there are no voices
  A. touching the client to help him return to reality

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  Nurses need to inform clients that there is a difference in perceptions and pay attention to the content of hallucinations. The other options are not therapeutic.

• Question 963:

  The nurse is assessing the newborn's respirations.

  Which of these findings would indicate a need for follow-up and further intervention?

  A. irregular respirations
  B. shallow respirations
  C. 70 breaths per minute
  D. abdominal respirations
  C. 70 breaths per minute

• Question 964:

  Which of the following terms refers to soft-tissue injury caused by blunt force?

  A. contusion
  B. strain
  C. sprain
  D. dislocation
  A. contusion

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  A contusion is a soft-tissue injury caused by blunt force. It is an injury that does not break the skin, is caused by a blow and is characterized by swelling, discoloration, and pain. The immediate application of cold might limit the development of a contusion. A strain is a muscle pull from overuse, overstretching, or excessive stress. A sprain is caused by a wrenching or twisting motion. A dislocation is a condition in which the articular surfaces of the bones forming a joint are no longer in anatomic contact.

• Question 965:

  Which atrioventricular heart block is also referred to as Mobitz II?

  A. Third-degree atrioventricular heart block.
  B. Second-degree atrioventricular heart block.
  C. First-degree atrioventricular heart block.
  D. Complete heart block.
  A. Third-degree atrioventricular heart block.

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  Third-degree atrioventricular heart block is also referred to as Mobitz II; this type of heart block occurs when the AV node impulses are blocked as they try to reach the ventricles. First degree heart block occurs when the AV node impulse is delayed. Second degree heart block, as referred to as Mobitz I and Wenckebach, occurs when there are progressive conduction delays through the AV node that alters the PR and QRS intervals. Complete heart block blocks all atrial impulses to the ventricle.

• Question 966:

  Which of the following physical findings indicates that an 11-12-month-old child is at risk for developmental dysplasia of the hip?

  A. refusal to walk
  B. not pulling to a standing position
  C. negative Trendelenburg sign
  D. negative Ortolani sign
  B. not pulling to a standing position

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  The nurse might be concerned about developmental dysplasia of the hip if an 11-12-month-old child doesn't pull to a standing position. An infant who does not walk by 15 months of age should be evaluated. Children should start walking between 11-15 months of age. Trendelenberg sign is related to weakness of the gluteus medius muscle, not hip dysplasia. Ortolani sign is used to identify congenital subluxation or dislocation of the hip in infants.

• Question 967:

  When giving an intramuscular injection to an infant. Which of the following sites is preferred?

  A. Ventrogluteal region
  B. Deltoid
  C. Vastus lateralis
  D. Dorsogluteal region
  C. Vastus lateralis

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  Vastus lateralis is the ideal choice for infants.

• Question 968:

  The nurse is caring for a postpartum woman who has relinquished her baby for adoption.

  The care plan for the client should include which of the following priority strategies?

  A. Make a referral for grief counseling.
  B. Allow the woman to see her baby initially, and then discourage further visits.
  C. Provide opportunities for the woman to express her feelings.
  D. Inform the woman she has the right to change her mind about relinquishment.
  C. Provide opportunities for the woman to express her feelings.

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  Most women who relinquish their infants at birth have come to that decision with a great deal of love and pain. They have made plans in advance. The nurse needs to first provide them with opportunities to express their feelings that might include grief, loneliness, and guilt. A referral for grief counseling might be appropriate if no other support system exists or the mother indicates that she wants assistance working through her grief. If the nurse assesses that the grief process is abnormal, a referral is also appropriate. The mother has probably already made a decision about whether or not she wants to see her baby. The nurse should ask her and make arrangements for that to happen if the mother requests it. Seeing the baby might aid in the grief process. Until relinquishment occurs, this is the mother's baby and she should be allowed to see it as often as she wants. The mother does have the right to change her mind until final legal arrangements are made. But suggesting this option might lead her to think that the nurse believes she shouldn't relinquish her baby.

• Question 969:

  A woman is in the active phase of labor. An external monitor has been applied, and a fetal heart deceleration of uniform shape is observed, beginning just as the contraction is under way and returning to the baseline at the end of the contraction.

  Which of the following nursing actions is most appropriate?

  A. Administer O2.
  B. Turn the client on her left side.
  C. Notify the physician.
  D. No action is necessary.
  D. No action is necessary.

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  It is an early deceleration as a result of head compression, and at this time no action is necessary. Close observation of the mother and baby is needed.

• Question 970:

  All of the following are common reasons that nurses are reluctant to delegate except __________.

  A. lack of self-confidence
  B. desire to maintain authority
  C. confidence in subordinates
  D. getting trapped in the "I can do it better myself" mindset
  C. confidence in subordinates

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  If a delegator has confidence in his subordinates and feels that a task will be performed correctly, he is more likely to delegate. Reasons that delegators are reluctant to delegate include their own lack of confidence, fear of losing authority or personal satisfaction, and feeling that the task can only be performed correctly if they do it themselves.