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Questions 227

NCLEX-PN

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Extract:


Question 1 of 5

A woman is admitted to the labor and delivery unit in a sickle cell crisis. Which of the following nursing actions is the HIGHEST priority?

Correct Answer: C

Rationale: Adequate hydration is the highest priority in sickle cell crisis to reduce blood viscosity, promote circulation, and prevent further sickling of red blood cells, which can exacerbate vaso-occlusive complications. Oxygen (
A) is secondary unless hypoxia is present, positioning (
B) is less critical, and antibiotics (
D) are not indicated without infection.

Question 2 of 5

Which is an expected finding in the normal newborn?

Correct Answer: B

Rationale: Acrocyanosis (bluish extremities) is normal in newborns due to immature circulation. Undescended testicles, absent sucking pads, and retractions are abnormal.

Extract:

If your patient is in pain most of the day, administer analgesic doses


Question 3 of 5

If your patient is in pain most of the day, administer analgesic doses

Correct Answer: B

Rationale: Regularly scheduled analgesics maintain consistent pain control.

Extract:

Congenital hip dysplasia is suspected when the assessment data indicates which of the following in the newborn?


Question 4 of 5

Presence of Ortalani's click

Correct Answer: A

Rationale: The presence of Ortalani's click when legs are abducted and asymmetry of gluteal folds are signs of congenital hip dysplasia.

Extract:


Question 5 of 5

An adult is receiving total parenteral nutrition (TPN). Which assessment is essential for the nurse to make?

Correct Answer: D

Rationale: Daily weights monitor fluid balance and nutritional status, critical for TPN to prevent overload or malnutrition. TPN is intravenous, not gastric, and bowel movements/sounds are less relevant.

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