NCLEX Questions, NCLEX RN Practice Questions Quizlet Questions, NCLEX-RN Questions, Nurselytic

Questions 149

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Question 1 of 5

An elderly client has a stage II pressure ulcer on her sacrum. During assessment of the client's skin, the nurse would expect to find:

Correct Answer: B

Rationale: A stage II pressure ulcer involves partial-thickness skin loss, appearing as a shallow crater with a nonpainful wound base.

Question 2 of 5

The nurse is caring for a client with a closed head injury. A late sign of increased intracranial pressure is:

Correct Answer: A

Rationale: Changes in pupil equality and reactivity are late signs of increased intracranial pressure, indicating neurological deterioration.

Question 3 of 5

During the second stage of labor, the baby's head becomes compressed because the mother has a narrow, bony pelvis. Which of the following is the most common result for the infant from this type of compression?

Correct Answer: C

Rationale: Cranial molding (
C) is the most common result of head compression during labor due to a narrow pelvis, as the infant's skull adapts to the birth canal. Cerebral palsy (
A), intellectual disability (
B), and epilepsy (
D) are not directly caused by this.

Question 4 of 5

Using Naegele's rule for estimating the due date for a pregnancy, if a client's last menstrual cycle started on September 6 and ended September 10, when is the client's approximate due date?

Correct Answer: C

Rationale: Naegele's rule: September 6 + 7 days = September 13, + 9 months = June 13, 2014. Closest is June 10 (
C), adjusting for approximation.

Question 5 of 5

The nurse is preparing to discharge a 60-year-old woman on warfarin (Coumadin) after mitral valve replacement. Which dietary restriction should the nurse advise the client to make?

Correct Answer: C

Rationale: Green beans are high in vitamin K, which can counteract warfarin’s anticoagulant effect. Other foods listed have minimal vitamin K.

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