This is part 2 of the NCLEX review questions that can serve as a reviewer for nurses planning to take the NCLEX examination. This is another multiple-choice type of questions consisting of 25-items that tests your knowledge on the basic topics in nursing such as Maternal/Newborn, Gastrointestinal, Genitourinary and Fundamentals of Nursing.
1. The nurse is assessing the pregnant client and noted pain starting from the back and radiating to the lower abdomen. Each contraction occurs every 5 minutes and lasts for 50-60 seconds. Based on the findings above, the client is in which stage of labor?
a. Early first stage
c. Second stage
d. Third stage
2. Prior to vaginal examination, the nurse reviews the care of intrapartum clients. Which one of the following statements is TRUE about cervical changes in a primipara client?
a. Effacement precedes dilatation
b. Effacement and dilatation occur simultaneously
c. Dilatation precedes effacement
d. Effacement is not necessary
3. The client in active labor tells the nurse about the urge to bear down. The nurse’s best response is:
a. “Push gently with the next contraction.”
b. “Take a deep breath and push now.”
c. “You probably need to move your bowels.”
d. “Do not bear down until the health team have examined you.”
4. The client is admitted to the labor and delivery area. The nurse checks for fetal descent, flexion, internal rotation, extension, external rotation and expulsion. These findings describe:
a. Phases of the first stage of labor
b. Cardinal movements of labor
c. Factors affecting labor
d. Factors that determine fetal position
5. The time of the delivery process depends on the client’s number of pregnancy. When caring for the client who’s a multipara, the nurse should expect that the second stage of labor will last for:
a. 30-60 minutes
b. 1-3 hours
c. 3-5 hours
d. 5-10 hours
6. The client in labor for the past 10 hours shows no change in cervical dilatation and has stayed 5-6 cm for the past 2 hours. Uterine contractions remain regular at 2-minute interval, lasting 40-45 seconds. Which is a priority action of the nurse?
a. Assess for presence of a full bladder.
b. Suggest placement of an internal uterine pressure catheter to determine adequacy of contractions.
c. Encourage the woman to do deep breathing techniques.
d. Suggest to physician that oxytocin augmentation be started to stimulate labor.
7. The nurse is caring for the client on the second postpartum day. The nurse should expect the client’s lochia to be:
a. Red and moderate
b. Continuous with red clots
c. Brown and scanty
d. Thin and white
8. The client is experiencing an early postpartum hemorrhage. Which item in the client’s care plan requires revision for care?
a. Inserting an indwelling urinary catheter
b. Fundal massage
c. Administration of oxytocics
d. Perineal pad count
9. To avoid any complications associated with labor, the nurse must have a keen eye for assessment. In the fourth stage of labor, the nurse observed that the client has a full bladder. The nurse knows that this increases the risk of what postpartum complication?
b. Disseminated Intravascular Coagulation (DIC)
10. The client is at the end of the first postpartum day. The nurse is assessing the client’s status. Which finding requires further evaluation at this time?
a. Uterus in the midline position
b. Firm, round uterus
c. Fundus 2 fingerbreadths above the umbilicus
d. Fundus 1 fingerbreadth below the umbilicus
11. Postpartum assessment of the newly delivered client includes checking the uterine fundus for firmness and position. On the second day postpartum, you expect the client’s fundus to be:
a. Slightly boggy and below the umbilicus
b. Soft and either deviated to the right or left side of the abdomen
c. Firm and two to three fingerbreadths below the umbilicus
d. Firm and two to three fingerbreadths above the umbilicus
12. The nurse checks the client’s perineum as part of postpartal assessment. Which of the following is NOT a normal characteristic of an episiotomy of a two-day postpartum client?
a. Inflammation along the suture line
c. Mild edema
d. Mild tenderness
Gastrointestinal and Genitourinary
13. The client has a calcium type of urinary tract calculi. The nurse is providing nutritional therapy to the client on proper food choices. The following is rich in calcium which can cause urinary tract calculi EXCEPT?
a. Sardines and salmon
b. Chocolate and cocoa
c. Ice cream and yogurt
d. Gelatin desserts
14. The nurse is caring for the pediatric client with Tracheoesophageal Fistula. Which of the following symptoms is observed in this condition?
a. Abdominal distention
b. Projectile vomiting
c. Fecal impaction
d. Paroxysmal abdominal pain
15. The nurse noticed that the client has a visible wave-like movement on exposed abdomen during and after feeding. Which of the following conditions would the nurse suspect?
b. Tracheoesophageal Fistula
c. Pyloric Stenosis
Fundamentals of Nursing
16. The charge nurse on the cardiac unit is assigned to give tasks to other nurses based on their knowledge and skills. Which of the following is the most appropriate assignment for a labor room nurse?
a. A postoperative coronary bypass client who is about to be discharged.
b. A newly admitted myocardial infarction client.
c. A client with unstable angina
d. A post-operative valve replacement client
17. The client presented with complaint of a burning sensation in the eye after splashing concentrated household cleaner in it. Which of the following nursing actions is a priority?
a. Place fluorescein drops in the eye.
b. Patch the client’s eye.
c. Test the client’s visual acuity.
d. Irrigate the eye continuously with normal saline solution for 10 minutes.
18. The nurse is feeding the client with spaghetti for lunch. The client suddenly experienced choking but can still cough. What is the first thing that the nurse should do in this situation?
a. Immediately perform Heimlich maneuver to expel the foreign body.
b. Initiate CPR to restore cardiac function.
c. Perform head-tilt chin lift maneuver to open airway.
d. Let the client cough until the foreign body is expelled.
19. The nurse is assisting the client to stand up in bed. The nurse also assesses the client if orthostatic hypotension will occur. The nurse should be aware of the following blood pressure?
a. 110/70 when standing and 110/70 when lying down
b. 150/90 when lying down and 140/80 when standing, and reports feeling dizzy
c. 140/80 when sitting and 140/80 when standing
d. 130/70 lying down and 130/80 when sitting, and reports shortness of breath
20. Upon palpation of the LLQ of the abdomen, the client with suspected appendicitis grimaced and verbalized pain on the RLQ. How should the nurse document the finding?
a. Murphy’s sign
b. Rovsing sign
c. Psoas sign
d. Obturator sign
21. The nurse is assessing the client which appears to be pale and weak and with a history of arterial blood circulation problem. Which of the following is the priority nursing intervention?
a. Elevate the legs
c. Take a rest
d. Give hard candy
22. The nurse will insert a urinary catheter to a male client. Which of the following steps is INCORRECT?
a. Insert 6-9 inches.
b. Position the client in a supine.
c. Instruct the client to inhale through the mouth.
d. Insert 2-3 inches.
23. A disease outbreak has affected numerous clients causing them to flock to the emergency department. In this situation, which of the following leadership style is most appropriate?
a. Directive leadership
b. Democratic leadership
c. Participative leadership
d. Republican leadership
24. Tasks should be delegated to the right person to avoid any possible errors. The charge nurse on duty wants to delegate a task to a new nurse in the ward. Which of the following guidelines should the charge nurse consider?
a. Demonstrated skill
b. Knowledge of nursing theories
c. Attitude and behavior
d. Current rank of the delegate
25. The nurse noticed that the delegated task is correctly accomplished. As a part of safe delegation and supervision, the nurse should:
a. Delegate another task
b. Provide feedback
c. Recommend the staff to other team members
d. Ask the client’s insight