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Questions 164

NCLEX-PN

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Question 1 of 5

A client with a recent spinal cord injury is experiencing dysreflexia and is noted to have a BP of $240 / 110$. The nurse's initial response should be to:

Correct Answer: B

Rationale: Elevating the head to a 45° angle helps reduce blood pressure in autonomic dysreflexia by promoting venous return and reducing intracranial pressure.

Question 2 of 5

The nurse is assisting with the care of a client who is scheduled to receive an oxytocin infusion to induce labor. The nurse should recognize that oxytocin infusion can lead to

Correct Answer: B

Rationale: Oxytocin can cause uterine hyperstimulation, leading to fetal distress and potential cesarean delivery.

Question 3 of 5

Which of the following signs is highly suggestive of impaired hearing in an infant?

Correct Answer: B

Rationale: Absence of babbling by 7 months is a red flag for hearing impairment, as infants typically begin vocalizing in response to sounds. Other signs are less specific to hearing.

Question 4 of 5

The nurse is caring for a 72-year-old client 1 day postoperative colectomy. The nurse finds increased work of breathing, diminished breath sounds at the bases with fine inspiratory crackles, respirations 12/min and shallow, and pulse oximetry 96% on 2 L oxygen. There is no jugular venous distension or peripheral edema. Pain is regulated with client-controlled morphine. Which prescription does the nurse anticipate?

Correct Answer: B

Rationale: Incentive spirometry promotes lung expansion and prevents atelectasis, which is likely causing the observed respiratory symptoms.

Question 5 of 5

The pediatric nurse is reinforcing education about medication administration to the parents of a 4-year-old client. Which statements made by the parents demonstrate correct understanding? Select all that apply.

Correct Answer: C

Rationale: Using an oral syringe ensures accurate dosing. Mixing with food, redosing after vomiting, involving the child in preparation, or punishing refusal are inappropriate.

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