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Questions 227

NCLEX-PN

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Extract:


Question 1 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 2 of 5

After abdominal surgery, a client has a nasogastric tube attached to low suctioning. The client becomes nauseated, and the nurse observes a decrease in the flow of gastric secretions. Which of the following nursing interventions would be MOST appropriate?

Correct Answer: B

Rationale: Nausea and decreased NG tube output suggest possible obstruction. Aspirating with a syringe confirms tube placement and checks for blockages by testing the pH of aspirate (0–4 indicates gastric placement). Irrigation (
A) uses normal saline, not distilled water, and only after placement confirmation. Antiemetics (
C) or tube replacement (
D) do not address the cause.

Question 3 of 5

The nurse is caring for a client with active tuberculosis who has a history of noncompliance. Which of the following actions by the nurse would represent appropriate care for this client?

Correct Answer: B

Rationale: Ask a family member to supervise daily compliance. Direct-observed therapy (DOT) is a recognized method for ensuring client compliance to the drug regimen. A program can be set up to directly observe the client taking the medication in the clinic, home, workplace or other convenient location.

Extract:

Which of the following symptoms listed below would indicate laryngeal nerve injury following thyroidectomy?


Question 4 of 5

Hoarseness.

Correct Answer: A

Rationale: Hoarseness is a sign of laryngeal nerve damage, which can occur during thyroid surgery.

Extract:


Question 5 of 5

A client comes to the emergency department complaining of headache, malaise, chills, fever, and a stiff neck. Vital sign assessment reveals a temperature elevation, increased heart and respiratory rates, and normal blood pressure. On physical examination, the nurse notes confusion, a petechial rash, nuchal rigidity, Brudzinski's sign, and Kernig's sign. What does Brudzinski's sign indicate?

Correct Answer: D

Rationale: Brudzinski's sign indicates meningeal irritation, as in meningitis. Other signs of meningeal irritation include nuchal rigidity and Kernig's sign. Brudzinski's sign doesn't indicate increased ICP, cerebral edema, or low CSF pressure.

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