RN exams clinical judgment practice questions set 70

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The correct answer is A: Unruptured membranes. Internal monitoring devices are inserted through the cervix and into the uterus, which can introduce bacteria and increase the risk of infection if the membranes are not ruptured. This can lead to serious complications for both the mother and the baby. Choice B (intravenous fluid) is incorrect because IV fluids are commonly used during labor to maintain hydration and provide necessary nutrients. Choice C (Fetus has known heart defect) is incorrect because internal monitoring devices are used to assess fetal heart rate and detect any abnormalities, making this condition a reason for monitoring rather than a contraindication. Choice D (must act quickly to improve placental blood flow and fetal oxygen supply) is incorrect because internal monitoring devices are usually used for continuous monitoring and do not require immediate intervention to be placed.

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The correct answer is A: Hyperglycemia. The patient's symptoms like lethargy, thirst, headache, increased urination are indicative of high blood sugar levels. Lethargy is a common symptom of hyperglycemia due to the body's inability to use glucose effectively. Thirst and increased urination occur as the body tries to get rid of excess glucose through urine. Headache can result from dehydration due to increased urination. To address hyperglycemia, the nurse may need to adjust the patient's parenteral nutrition, monitor blood glucose levels, and potentially administer insulin. Incorrect choices: B: Hypoglycemia - Symptoms of hypoglycemia include sweating, confusion, and shakiness, which are not present in this case. C: Hypercapnia - This is high carbon dioxide levels in the blood, typically caused by respiratory issues, not related to the symptoms described. D: Hypocapnia - This is low carbon dioxide levels

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The correct answer is C: Recognizing triggers that cause asthma attacks. This is the priority goal because identifying triggers helps the client avoid or minimize asthma attacks, leading to better management of the condition. By recognizing triggers, the client can take proactive measures to prevent exacerbations. Choices A, B, and D are important aspects of asthma management, but recognizing triggers is crucial for preventing asthma attacks and improving overall quality of life. Maintaining a regular exercise routine (A) can be beneficial but may not be the priority if triggers are not controlled. Complying with medication instructions (B) is important for treatment adherence, but identifying triggers can help reduce the need for rescue medications. Understanding physical limitations (D) is important for self-management, but recognizing triggers is more directly related to preventing asthma exacerbations.

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The correct answer is B: Respiratory rate of 8 breaths/min. Morphine is an opioid that can cause respiratory depression as a side effect. A respiratory rate of 8 breaths/min indicates hypoventilation, which is a potential adverse effect of morphine. This is a critical finding that requires immediate intervention to prevent respiratory failure or arrest. A: Voiding of 350mL of concentrated urine in 8 hours is not directly related to morphine's adverse effects. Morphine can cause urinary retention, not increased voiding. C: Irregular heart rate of 82 beats/min is within normal range and not a typical adverse effect of morphine. Morphine can cause bradycardia or tachycardia, but not irregular heart rate specifically. D: Pupils constricted and equal is a common side effect of morphine due to its effect on the central nervous system. This finding does not suggest an adverse effect; it is an expected pharmac

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The correct answer is C: A 30-year-old male with hypotension, JVD, and tracheal deviation after chest trauma. This patient most likely has tension pneumothorax, a life-threatening condition where air accumulates in the pleural space causing mediastinal shift, JVD, and hypotension. Needle decompression is the initial treatment to relieve pressure and restore lung function. A: A chest wall contusion with absent breath sounds suggests a potential rib fracture but not a tension pneumothorax. B: Bilateral wheezing and difficulty breathing are more indicative of an asthma exacerbation or COPD exacerbation, not tension pneumothorax. D: Chest pain and productive cough are more commonly associated with conditions like pneumonia or bronchitis, not tension pneumothorax. In summary, the key features of tension pneumothorax are hypotension, JVD, and tracheal deviation after chest trauma, necessitating needle

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The correct answer is B. Monitoring hormone levels during ovulation induction is essential to ensure that the hormones stay within safe and effective ranges for successful egg maturation. By closely monitoring hormone levels, healthcare providers can adjust medication dosages as needed to optimize the chances of successful ovulation. This helps to minimize the risk of overstimulation or understimulation of the ovaries, which can impact the quality of the eggs produced. A: Predicting embryo quality before fertilization is not the primary purpose of monitoring hormone levels during ovulation induction. C: Confirming pregnancy before the cycle ends is not the purpose of hormone level monitoring during ovulation induction. D: Determining if the uterine lining is ready for implantation is important, but this is typically assessed through other methods such as ultrasound rather than hormone level monitoring.

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Dr. Langley's work being focused on understanding constancy and change throughout the lifespan aligns with the field of developmental science, which studies how individuals grow and change from birth through old age. This field encompasses the study of physical, cognitive, social, emotional, and other aspects of development across the lifespan. Choice A, genetics, primarily focuses on the study of genes, heredity, and genetic variation, which is not directly related to understanding constancy and change throughout the lifespan. Choice B, clinical psychology, concentrates on the diagnosis and treatment of mental, emotional, and behavioral disorders rather than the broader study of development across the lifespan. Choice C, adolescent development, is more specific and limited in scope compared to the comprehensive study of development across the entire lifespan, which is the focus of developmental science.

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The correct answer is A: Kidney, ureter, bladder (KUB) x-ray. KUB x-ray is a noninvasive diagnostic procedure that provides information about the size, shape, and position of the kidneys, ureters, and bladder. It can help detect abnormalities such as kidney stones or structural issues. Rationale: 1. KUB x-ray is noninvasive, meaning it does not require any incisions or insertion of instruments into the body. 2. It is commonly used as an initial screening tool to assess kidney function. 3. Renal ultrasound (Choice B) is also noninvasive but primarily used for imaging the kidneys and not the entire urinary system. 4. MRI (Choice C) and IVP (Choice D) are more invasive procedures that involve injecting contrast agents and may not be routinely used for initial kidney function assessment. In summary, the KUB x-ray is the correct choice as it is a noninvasive procedure specifically designed to evaluate kidney

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The correct answer is B: Empty your bladder before the procedure. This is the priority preoperative instruction because a full bladder can increase the risk of complications during surgery, such as injury to the bladder or difficulties in catheter insertion. It is essential to ensure the bladder is empty to provide a clear surgical field and prevent urinary retention postoperatively. Explanation for other choices: A: Eating a high-protein meal before surgery is not recommended as it can increase the risk of aspiration during anesthesia. C: Avoiding brushing teeth on the morning of surgery is not a priority instruction. Maintaining oral hygiene is important, but it does not directly impact the surgical procedure. D: Refraining from taking prescribed medications should be discussed with the healthcare provider, as certain medications may need to be taken even on the day of surgery to prevent complications.

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The correct answer is A: Splitting. Splitting is a defense mechanism commonly seen in individuals with borderline personality disorder where they perceive others as either all good or all bad. In this scenario, the patient's sudden shift from viewing the nurse as wonderful to hateful demonstrates splitting. The patient is unable to integrate both positive and negative aspects of the nurse's behavior, leading to extreme and polarized perceptions. Choice B: Denial involves refusing to accept reality to protect oneself from uncomfortable truths, which is not demonstrated in this response. Choice C: Reaction formation is a defense mechanism where an individual behaves in a way that is opposite to their true feelings, which is not evident in the patient's response. Choice D: Projection involves attributing one's own unacceptable thoughts or feelings onto someone else, which is not the case in this scenario.