NCLEX Questions, NCLEX PN Practice Test Questions, NCLEX-PN Questions, Nurselytic

Questions 164

NCLEX-PN

NCLEX-PN Test Bank

NCLEX PN Practice Test Questions

Extract:


Question 1 of 5

A client in labor with a history of a previous cesarean birth has chosen to attempt a vaginal birth. During labor, which finding would be most concerning to the nurse?

Correct Answer: A

Rationale: Cessation of contractions with maternal tachycardia (
A) suggests uterine rupture, a life-threatening emergency in VBAC due to scar dehiscence. Fetal tachycardia (
B) is concerning but less specific, anxiety (
C) is expected, and regular contractions (
D) are normal.

Question 2 of 5

The nurse is performing rounding on clients in restraints. Which situation would require immediate intervention by the nurse?

Correct Answer: D

Rationale: A vest restraint in the high-Fowler position (
D) poses a risk of strangulation or asphyxiation due to the restraint slipping upward, requiring immediate intervention. Belt restraint in semi-Fowler (
A), mitten restraints in side-lying (
B), and wrist restraints in supine (
C) are safer positions, assuming proper application and monitoring.

Question 3 of 5

To maintain Bryant's traction, the nurse must make certain that the child's:

Correct Answer: B

Rationale: Bryant's traction requires hips slightly elevated and legs at a right angle to the bed to align the femur properly and reduce pressure on the pelvis.

Question 4 of 5

A nurse is caring for a 1-month-old client who is being evaluated for congenital hypothyroidism. The nurse should recognize which of the following as clinical manifestations of hypothyroidism in infants? Select all that apply.

Correct Answer: A,B,D

Rationale: Hypothyroidism in infants causes lethargy (
A), dry skin (
B), and hoarse cry (
D) due to slowed metabolism. Loose stools (
C) and tachycardia (E) are more typical of hyperthyroidism.

Question 5 of 5

The nurse is caring for a client who has a single-chamber atrial pacemaker. Which of the following findings would the nurse expect to observe on the client’s electrocardiogram strip?

Correct Answer: B

Rationale: A single-chamber atrial pacemaker paces the atrium, producing a spike before the P wave (
B), followed by normal conduction. Spikes on T waves (
A) are abnormal, wide QRS (
C) suggests ventricular issues, and prolonged PR (
D) is unrelated to pacing.

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