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

Questions 148

NCLEX-RN

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Question 1 of 5

A client has a CVP monitor in place. Which would be included in the nursing care plan for this client?

Correct Answer: A

Rationale: CVP readings outside 3-8 cm of water may indicate fluid imbalance or catheter issues, requiring physician notification to prevent complications.

Question 2 of 5

A client has a chest tube in place with a three-chamber chest drainage system. The nurse notes continuous bubbling in the water seal chamber. This indicates which of the following?

Correct Answer: C

Rationale: Continuous bubbling in the water seal chamber indicates a system air leak (
C), such as a loose connection or hole in the tubing. A pneumothorax (
A) may cause intermittent bubbling, adequate suction (
B) is indicated by bubbling in the suction chamber, and incorrect tube positioning (
D) would not typically cause continuous bubbling.

Question 3 of 5

The nurse is calculating the Apgar score for a newborn. Findings are as follows: Heart rate: 110, Respiratory effort: good cry, Muscle tone: some flexion of extremities, Reflex irritability: grimace, Color: completely pink. What is the Apgar score for this neonate?

Correct Answer: C

Rationale: Heart rate 110 (2), good cry (2), some flexion (1), grimace (1), pink (2) = 9.

Question 4 of 5

The nurse is assessing a client with suspected hypoparathyroidism. Which of the following findings would the nurse expect?

Correct Answer: A

Rationale: muscle cramps and tetany are signs of hypoparathyroidism due to hypocalcemia

Question 5 of 5

A 5-year-old client with hyperthyroidism is admitted to the pediatric unit. What would the nurse expect the admitting assessment to reveal?

Correct Answer: C

Rationale: Exophthalmos (bulging eyes) is a common sign of hyperthyroidism due to thyroid hormone effects on orbital tissues.

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