2022/2023 NCLEX-PN Test Prep

2(TWO)

Questions and Answers with Explanations

1. When assessing a laboring client, the nurse finds a prolapsed cord. The

nurse should:

A. Attempt to replace the cord

B. Place the client on her left side

C. Elevate the client’s hips

D. Cover the cord with a dry, sterile gauze

Answer C: The client with a prolapsed cord should be treated by elevating

the hips and covering the cord with a moist, sterile saline gauze. The nurse

should use her fingers to push up on the presenting part until a Caesarean

section can be performed. Do not attempt to replace the cord, as stated in

answer A. Answer B is incorrect because turning the client to the left side

will not help take pressure off the cord. Answer D is incorrect because the

cord should be covered with a moist, sterile gauze, not dry gauze.

2. The nurse is caring for a 30-year-old male admitted with a stab

wound. While in the emergency room, a chest tube is inserted. Which of

the following explains the primary rationale for insertion of chest tubes?

A. The tube will allow for equalization of the lung expansion.

B. Chest tubes serve as a method of draining blood and serous fluid, and

assist in reinflating the lungs.

C. Chest tubes relieve pain associated with a collapsed lung. D. Chest

tubes assist with cardiac function by stabilizing lung expansion.

Answer B: Chest tubes work to reinflate the lung and drain serous fluid. The

tube does not equalize expansion of the lungs, so answer A is incorrect. Pain

is associated with collapse of the lung, and insertion of chest tubes is painful,

so answer C is incorrect. Answer D is true but is not the primary rationale for

performing chest tube insertion.