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Questions 227

NCLEX-PN

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Extract:

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


Question 1 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 2 of 5

Which of the following nursing assessments for an infant is most valuable in identifying serious visual defects?

Correct Answer: A

Rationale: Red reflex test. A uniform red reflex rules out most serious defects of the cornea, lens, and vitreous chamber.

Question 3 of 5

The licensed practical nurse is preparing to administer an injection of vitamin K to a newborn. The nurse should administer the injection in the:

Correct Answer: B

Rationale: The vastus lateralis is the preferred site for newborn IM injections due to its large muscle mass and safety. Other sites are less developed or risk nerve damage.

Question 4 of 5

All of the following adults are admitted to the surgical unit. Which client should the nurse prepare for immediate surgery?

Correct Answer: C

Rationale: Severe right lower quadrant pain with elevated WBC suggests appendicitis, requiring immediate surgery to prevent rupture. Scapular pain (gallbladder), vaginal bleeding, or hernia are less urgent unless complicated.

Extract:

The day before a patient who has had a subtotal gastrectomy is to be discharged, the patient complains of perspiring and having epigastric discomfort about a half hour after eating lunch. The symptoms disappear within a few minutes.


Question 5 of 5

The nurse recognizes that the teaching about prevention is understood when the patient states, 'I can limit these symptoms by:

Correct Answer: D

Rationale: Small, low-carbohydrate meals reduce dumping syndrome symptoms post-gastrectomy.

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