Pass the NCLEX NCLEX-PN Questions and answers with ValidTests

A stab wound to the chest might result in lung collapse and mediastinal shift that, if untreated, could lead to

death. Treatment of an obstructed airway or a chest wound is a higher priority than hemorrhage. The principle of

ABC (airway, breathing, and circulation) prioritizes care decisions.Physiological Adaptation

The amount of alcohol that is safe during pregnancy is unknown. Fetal alcohol syndrome is a combination

of mental and physical abnormalities present in infants born to mothers who have consumed alcohol during

pregnancy.Psychosocial Integrity

Decreasing maternal fluids is the only intervention that shouldnotbe performed when fetal distress is

indicated.Reduction of Risk Potential

Clients with renal disease are predisposed to hyperkalemia and should avoid foods high in potassium.

Choices 1, 2, and 3 are incorrect because clients receiving diuretics with ileostomy or with metabolic alkalosis

are at risk for hypokalemia and should be encouraged to eat foods high in potassium.Physiological Adaptation

Pernicious anemia results from vitamin B12 deficiency due to lack of intrinsic factor. This can result from

inadequate dietary intake, faulty absorption from the GI tract due to a lack of secretion of intrinsic factor

normally produced by gastric mucosal cells and certain disorders of the small intestine that impair absorption.

The nurse should instruct the client in the need for lifelong replacement of vitamin B12, as well as the need for

folic acid, rest, diet, and support.Physiological Adaptation

Nutrition, elimination, comfort, and safety are the major areas of importance. The diet should be high in

protein with adequate fluids.Basic Care and Comfort

These ABG values are within normal limits. Choices 1, 3, and 4 are incorrect because the ABG values

indicate none of these acid-base disturbances.Physiological Adaptation

Perimenopause refers to a period of time in which hormonal changes occur gradually, ovarian function

diminishes, and menses become irregular. Perimenopause lasts approximately five years. Climacteric is a term

applied to the period of life in which physiologic changes occur and result in cessation of a woman’s reproductive

ability and lessened sexual activity in males. The term applies to both genders. Climacteric and menopause are

interchangeable terms when used for females. Menopause is the period when permanent cessation of menses has

occurred. Postmenopause refers to the period after the changes accompanying menopause are complete.Health

Promotion and Maintenance

The hands are cupped for performing percussion, producing a vibration that helps loosen respiratory secretions.

The other hand positions do not accomplish this task.Reduction of Risk Potential

Huntington’s chorea is characterized by writhing, twisting movements of the face and limbs. The remaining

options are neurological disorders that do not have such movements as part of their disease process.Reduction of

Risk Potential

The hands are flattened over the area of the body where chest percussion is used to conduct vibration through

to the chest and loosen secretions. The other hand positions do not accomplish this task.Reduction of Risk

Potential

Prevention of child abuse is centered on teaching the parents how to care for their child and cope with the

demands of infant care. Parenting classes can help build self-confidence, self-esteem, and coping skills. Parents

benefit by understanding the developmental needs of their children, while learning how to manage their home

environment more effectively. The classes also increase the parents’ social contacts and teach about community

resources.Psychosocial Integrity

The usual recommendation for treatment of hypoglycemia is 10–15 grams of a fast-acting simple carbohydrate,

orally, if the client is conscious and able to swallow (for example, 3–4 commercially prepared glucose tablets or 4–6

oz of fruit juice). It is not necessary to add sugar to juice, even if it is labeled as unsweetened juice because the fruit

sugar in juice contains enough simple carbohydrate to raise the blood glucose level. Addition of sugar might result in a sharp rise in blood sugar that could last for several hours.Physiological Adaptation

There are several guidelines for evaluating kinetic family drawings, including Choice 4. Effective nursing

actions include asking the child to explain what each family member is doing, encouraging him or her to tell as

much as possible about the drawing, noting physical intimacy or distance, noting placement of family members in

the drawing, noting facial expressions of family members and noting if they are facing each other or turned away.

Choice 1 is initial instruction, not evaluation. Only general encouragement should be given to avoid suggesting

themes to the child.Health Promotion and Maintenance

Zofran is a serotonin antagonist that can be used to relieve nausea and vomiting. The other medications can

be used for nausea and vomiting, but they have different mechanisms of action.Physiological Adaptation