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Questions 163

NCLEX-PN

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Question 1 of 5

A nurse is caring for a child who is receiving oxygen at 2 L/min by nasal cannula and observes the current oxygen saturation and pulse plethysmographic waveform on the pulse oximeter. Which intervention should be the nurse's initial action?

Correct Answer: D

Rationale: An inaccurate pulse oximeter reading may result from a poorly positioned probe. Verifying the probe's position is the initial action. Auscultation , deep breaths , or increasing oxygen are secondary without confirming the reading.

Question 2 of 5

The nurse is observing a staff member caring for a client who has varicella with active lesions. The nurse should intervene if the staff member is observed

Correct Answer: C

Rationale: Removing an N95 mask inside the room of a varicella client risks airborne exposure, requiring intervention. Other actions (A, B,
D) follow correct infection control protocols.

Question 3 of 5

The licensed practical nurse (LPN) is assisting the registered nurse in caring for 4 clients. Which client is at greatest risk for the development of deep venous thrombosis?

Correct Answer: D

Rationale: An 80-year-old post-hip surgery client is at highest DVT risk due to age, immobility, and recent surgery. Smoking and contraceptives , elevated hematocrit , and stent with fever carry risks but are less immediate.

Question 4 of 5

A 36 year-old female client has a hemoglobin level of 14 g/dl and a hematocrit of 42% following a D&C. Which of the following would the nurse expect to find when assessing this client?

Correct Answer: A

Rationale: Capillary refill less than 3 seconds. Since the hemoglobin and hematocrit are normal for an adult female, additional assessments should be normal. This capillary refill time is normal.

Question 5 of 5

A client indicates to the nurse a desire to become pregnant. The client drinks 1-2 glasses of wine on weekends. BMI is 32 kg/m². Which teachings should the nurse reinforce as part of proper preconception health care for this client? Select all that apply.

Correct Answer: A,B,D,E

Rationale:
To optimize preconception health: Avoid undercooked meat to prevent toxoplasmosis; limit alcohol to minimal or none to avoid fetal alcohol syndrome; rubella vaccine prevents congenital rubella syndrome; and folic acid reduces neural tube defects. A BMI of 32 is obese and should be reduced for healthier pregnancy outcomes.

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