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Questions 163

NCLEX-PN

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Question 1 of 5

In response to a call for assistance by a client in labor, the nurse notes that a loop of the umbilical cord protrudes from the vagina. What is the priority nursing action?

Correct Answer: C

Rationale: Immediate action is needed to relieve pressure on the cord, which puts the fetus at risk due to hypoxia. The knee-chest position accomplishes this. The exposed cord is covered with saline-soaked gauze, not reinserted.

Question 2 of 5

The nurse is reinforcing information about techniques to improve sleep habits with a client who experiences frequent insomnia. Which statement by the client requires further teaching?

Correct Answer: C

Rationale: Reading in bed associates the bed with wakefulness, requiring further teaching. Avoiding naps , cool temperature , and consistent sleep schedule promote sleep hygiene.

Question 3 of 5

An elderly man has just returned from the operating room where he spent several hours in lithotomy position during a perineal prostatectomy. Which assessment should the nurse make because the client was in lithotomy position during surgery?

Correct Answer: A

Rationale: Prolonged lithotomy position risks nerve compression and impaired circulation in the lower extremities, necessitating assessment of pulses, paresthesias, and pain to detect complications like compartment syndrome.

Question 4 of 5

The nurse observes a nursing assistant caring for an 86-year-old woman who had an open reduction/internal fixation for a fractured femur two days ago. Which action by the nursing assistant needs correction by the nurse?

Correct Answer: B

Rationale: Full weight-bearing two days post-femur fixation is inappropriate, risking hardware failure; partial or non-weight-bearing is typical. Abductor pillows, commodes, and self-bathing are appropriate.

Question 5 of 5

The postoperative client on hydrocodone becomes hypoxic, and naloxone is administered per protocol. What is most important for the nurse to consider in the follow-up care of this client?

Correct Answer: A

Rationale: After naloxone administration for opioid-induced hypoxia, monitoring respiratory status is critical as naloxone's effects are short-acting, and respiratory depression may recur. Documentation is important but secondary, changing analgesics is not immediate, and drug interactions are less urgent.

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