NCLEX Questions, NCLEX Trainer Test 1 Questions, NCLEX-PN Questions, Nurselytic

Questions 157

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Question 1 of 5

During the check up of a 2 month-old infant at a well baby clinic, the mother expresses concern to the nurse because a flat pink birthmark on the baby's forehead and eyelid has not gone away. What is an appropriate response by the nurse?

Correct Answer: C

Rationale: Telangiectatic nevi, salmon patch or stork bite birthmarks, are a normal variation and the facial nevi will generally disappear by ages 1 to 2 years.

Question 2 of 5

The nurse is inserting an indwelling urinary catheter in an adult woman. The nurse locates landmarks before inserting the catheter. The urethral opening is located:

Correct Answer: C

Rationale: The female urethral opening is located between the clitoris and vagina, a key landmark for catheter insertion to avoid incorrect placement.

Question 3 of 5

The nurse in the newborn nursery receives report from the previous shift. Which of the following infants should the nurse see FIRST?

Correct Answer: A

Rationale: A heart rate of 185 bpm indicates tachycardia (normal 120–160 bpm), suggesting distress or dehydration, requiring immediate assessment. Options B, C, and D are less urgent or normal.

Question 4 of 5

A woman who was recently widowed says to the nurse, 'I just can't believe he's gone. Sometimes I even think I see him standing there.' What does this comment indicate about the client?

Correct Answer: A

Rationale: Disbelief and transient perceptions of the deceased are normal in early grief. Hallucinations, illusions, or depression require more persistent or severe symptoms.

Question 5 of 5

Which of the following is a correctly stated nursing diagnosis for a client with abruptio placentae?

Correct Answer: D

Rationale: Abruptio placentae causes hemorrhage, leading to fluid volume deficit, a major nursing concern. The other options are incorrectly stated or irrelevant: infection is not typical, ‘potential’ diagnoses are not standard, and fibrinogen depletion is not the primary issue.

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