Published - Thu, 23 Feb 2023

NCLEX-RN Exam Questions - Part 45

1. While the RN is assessing a mother - s perineum on her 2nd postpartum day after having a vaginal delivery, the RN notes a large ecchymotic area located to the left of the mother - s perineum. Which one of the following interventions should the RN initiate at this time?

A) Have the client expose the area to air.
B) Apply ice to the perineum.
C) Encourage the client to take warm sitz baths.
D) Inform the physician.

2. A mother who is breast-feeding her newborn asks the RN, 'How can I express milk from my breasts manually?' The RN tells her that the correct method for manual milk expression includes using the thumb and the index finger to:

A) Alternately compress and release each nipple
B) Roll the nipple and gently pull the nipple forward
C) Slide the thumb and index finger forward from the outer border of the areola toward the end of the nipple
D) Compress and release each breast at the outer border of the areola

3. A client had a vaginal delivery 3 days ago and is discharged from the hospital on the 2nd day postpartum. She told the RN, 'I need to start exercising so that I can get back into shape. Could you suggest an exercise I could begin with? The RN could suggest which one of the following?

A) Push-ups
B) Jumping jacks
C) Leg lifts
D) Kegel exercises

4. A 60-year-old male client was hospitalized 3 days ago with the diagnosis of acute anterior wall myocardial infarction. Today he has been complaining of increasing weakness and shortness of breath. Crackles in both lung bases are audible on auscultation. He is developing:

A) An extension of his myocardial infarction
B) Pneumonia
C) Pulmonary edema
D) Pulmonary emboli

5. On admission, the client has signs and symptoms of pulmonary edema. The nurse places the client in the most appropriate position for a client in pulmonary edema, which is:

A) High Fowler
B) Lying on the left side
C) Sitting in a chair
D) Supine with feet elevated

1. Right Answer: C
Explanation: (A) The area is bruised and painful. This action would do nothing to help with the healing process of the perineum or to provide comfort. (B) Ice is effective immediately after birth to reduce edema and discomfort, but not on the 2nd postpartum day. (C) Sitz baths are useful if the perineum has been traumatized, because the moist heat increases circulation to the area to promote healing, relaxes tissue, and decreases edema. (D) The physician is not notified of bruising, but if a hematoma is present, then the physician is notified.

2. Right Answer: D
Explanation: (A) Manipulation of nipples will cause soreness and trauma. (B) Pulling the nipples will cause discomfort and soreness. (C) Sliding the thumb and index finger forward over the nipple will cause soreness. (D) The best method to express milk from the breast is to position the thumb and index finger at the outer border of the areola and compress. This is the location of the milk sinuses.

3. Right Answer: D
Explanation: (A, B, C) This exercise is too strenuous at this time. (D) This exercise is recommended for the first few days after delivery. It helps to stimulate muscle tonus in the area of the perineum and the area around the urinary meatus and vagina.

4. Right Answer: C
Explanation: (A) Extensions of his myocardial infarction would be chest pain unrelieved with nitroglycerin, cardiac enzyme elevations, and electrocardiographic changes. (B)Persons with pneumonia may complain of weakness and shortness of breath and have crackles in their lung bases. However, they would also have sputum production and leukocytosis. (C) Persons who have had myocardial infarctions (especially anterior wall) are at risk of developing left ventricular heart failure, which is a major cause of pulmonary edema. Pulmonary edema is manifest by shortness of breath, weakness, and crackles on auscultation of the lung fields. (D)Pulmonary emboli may be accompanied by shortness of breath, weakness, and crackles. However, the pulmonary hypertension that accompanies pulmonary emboli results in signs of increased systemic venous pressure as well.

5. Right Answer: A
Explanation: (A) High Fowler position decreases venous return to the heart and permits greater lung expansion so that oxygenation is maximized. (B) Lying on the left side may improve perfusion to the left lung but does not promote lung expansion. (C) Sitting in a chair will decrease venous return and promote maximal lung expansion.However, clients with pulmonary edema can deteriorate quickly and require intubation and mechanical ventilation. If a client is sitting in achair when this deterioration happens, it will be difficult to intervene quickly. (D) The supine with feet elevated position increases venous return and will worsen pulmonary edema.

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