NCLEX Questions, NCLEX RN Practice Questions, NCLEX-RN Questions, Nurselytic

Questions 148

NCLEX-RN

NCLEX-RN Test Bank

NCLEX RN Practice Questions

Extract:


Question 1 of 5

A 5-year-old child is hospitalized for correction of congenital hip dysplasia. During the assessment of the child, the nurse can expect to find the presence of:

Correct Answer: D

Rationale: Trendelenburg sign is associated with congenital hip dysplasia, where the pelvis tilts downward on the unaffected side when the child stands on the affected leg, indicating hip instability.

Question 2 of 5

A client has had a central catheter inserted for administration of parenteral nutrition. An X-ray was taken to ensure correct positioning prior to commencing infusions. The X-ray report indicates that the catheter tip is in the right atrium. Which of the following actions by the nurse is correct?

Correct Answer: A

Rationale: Catheter tip in the right atrium is too far; infusion should be held and the MD notified (
A) for repositioning. Adjusting the catheter (B,
D) or starting infusion (
C) is unsafe.

Question 3 of 5

The client admitted 2 days earlier with a lung resection accidentally pulls out the chest tube. Which action by the nurse indicates understanding of the management of chest tubes?

Correct Answer: C

Rationale: Covering the insertion site with Vaseline gauze prevents air from entering the pleural space, which is the priority action for a dislodged chest tube.

Question 4 of 5

A client returns from surgery with a total knee replacement. Which of the following findings requires immediate nursing intervention?

Correct Answer: B

Rationale: A CPM set at 90° flexion immediately post-knee replacement is excessive and could damage the surgical site, requiring immediate adjustment.

Question 5 of 5

The nurse is caring for clients on the postpartum unit. Which of the following should the nurse assess first?

Correct Answer: C

Rationale: A placenta delivered 10 minutes after the infant is at risk for retained fragments, which can cause postpartum hemorrhage, requiring immediate assessment.

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