NCLEX Daily Ten Question Practical Exercise 4

Welcome to our NCLEX Daily Ten Practice! This practice is designed to help you solidify your knowledge, improve your skills, and prepare thoroughly for the NCLEX exam. With ten questions to tackle each day, you’ll have the opportunity to review a broad range of subjects covered in the NCLEX exam.

 

1. A nurse reviews laboratory results from four clients. The nurse should first assess the client with?

A. a deep vein thrombosis who has an increased D-dimer
B. chemotherapy who has a decreased white blood cell count
C. diabetes mellitus who has an elevated glycated hemoglobin (A1C)
D. an acute kidney injury who has an elevated serum potassium level

Correct Answer: D

Answer Explanation:

Kidneys excrete the majority of the body’s potassium. When renal tissue is impaired (e.g., acute kidney injury [AKI]), serum potassium levels can rise to dangerous levels. Potassium plays an important role in the electrical conduction system of the heart. Hyperkalemia places the client at high risk for life-threatening cardiac arrhythmias like ventricular fibrillation. The nurse should assess this client first for signs of hyperkalemia (e.g., nausea, chest pain, muscle weakness) and initiate close cardiac monitoring.

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2. The nurse is caring for a laboring client who is showing a sudden decrease in fetal heart rate following an amniotomy. Which of the following interventions should the nurse take?

A. Apply a vibroacoustic stimulator.
B. Prepare for an abdominal ultrasound.
C. Obtain an intrauterine pressure catheter.
D. Place the client in knees-to-chest position.

Correct Answer: D

Answer Explanation:

Umbilical cord prolapse occurs when the cord protrudes into the cervix/vagina in front of the fetal presenting part. It is characterized by fetal heart rate (FHR) decelerations, most frequently following membrane rupture (e.g., amniotomy). When cord prolapse occurs, the presenting part compresses the umbilical cord (e.g., fetal head), preventing blood flow to the fetus and causing fetal hypoxia.
If cord prolapse is suspected, the nurse should place the client in Trendelenburg, modified Sims, or knee-to-chest position. These positions use gravity to reduce cord compression and prevent further pelvic engagement by the presenting part. Additionally, the nurse should perform a vaginal exam, assessing for the umbilical cord (e.g., palpable pulsating loop). If confirmed, the nurse should lift the presenting part off the umbilical cord, reducing compression and improving fetal oxygenation until delivery via emergent cesarean section.

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3. The nurse is caring for a client 4 hours postpartum and reviews the Assessment from 1000.

Nclex1 1

Which of the following actions should the nurse take first?

A. Perform fundal massage.
B. Insert an intermittent urinary catheter.
C. Apply a fresh ice pack to the perineum.
D. Assess the perineum for localized bleeding.

Correct Answer: B

Answer Explanation:

Bladder distention displaces the uterus away from the midline (i.e., umbilicus) and pushes it upward (e.g., U+2). A full bladder interferes with uterine descent and impedes uterine contractions, causing uterine atony (i.e., relaxed, boggy, hypotonic).  With uterine atony, the uterus is unable to contract properly to clamp uterine arteries and prevent excessive bleeding. To improve uterine tone and prevent further bleeding and postpartum hemorrhage (PPH), the nurse should empty the client’s bladder (e.g., assist to the bathroom, in and out urinary catheterization).

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4. The nurse is talking with a client whose child recently passed away following a diagnosis of cancer two years prior. Which of the following would be an appropriate response for the nurse to make regarding this recent loss?

A. “Be grateful for the time you had together when your child was alive.”
B. “Your child is in heaven now, and you will see each other again someday.”
C. “This is a big change for you. l can’t begin to imagine how you are feeling.”
D. “You’re still young, so there is plenty of time for you to have more children.”

Correct Answer: C

Answer Explanation:

When caring for clients who have experienced loss, the nurse should use therapeutic communication to assess the client’s coping. Making broad observations such as, “This is a big change for you,” neutrally acknowledges the client’s situation and shows empathy towards the client’s experience without making assumptions. “I can’t begin to imagine how you are feeling” provides an opportunity for the client to express their emotions, encouraging further conversation about how they are coping with this loss.

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5. The nurse is observing a coworker administering subcutaneous insulin lispro to a client with diabetes. Which of the following actions by the coworker would require the nurse to intervene?

A. Administers insulin lispro 1 hour before meal trays arrive
B. Marks an expiration date on the vial that is 28 days from today
C. Stores the opened vial of insulin in a secure medication cabinet
D. Administers the injection into adipose tissue on the client’s abdomen

Correct Answer: A

Answer Explanation:

Insulin should be administered no earlier than the duration of the onset of action for the specific insulin formulation. Rapid-acting insulins (i.e., lispro, aspart) have an onset of action in 15-30 minutes and a peak effect between 1-3 hours. Giving insulin lispro 1 hour before mealtime could precipitate hypoglycemia. The nurse should instead administer insulin lispro within 15-30 minutes of the planned meal (the onset of action for rapid-acting insulin).

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