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Questions 160

NCLEX-PN

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Extract:


Question 1 of 5

The nurse is assessing a newborn with suspected jaundice. Which finding confirms the presence of jaundice?

Correct Answer: A

Rationale: Yellowing of the sclera is a hallmark sign of jaundice due to bilirubin accumulation.

Question 2 of 5

What are the priorities when planning the care of a 75-year-old hospitalized client who develops pneumonia? Select all that apply.

Correct Answer: B,E,F

Rationale: Maintaining oxygenation addresses hypoxia, a critical issue in pneumonia. Administering antibiotics promptly and obtaining blood cultures ensure timely treatment and accurate diagnosis.

Question 3 of 5

While visiting a client who takes a prescribed diuretic, how can a home health care nurse best evaluate the drug's effectiveness?

Correct Answer: A

Rationale: Diuretics reduce fluid retention, leading to weight loss. Monitoring weight is the best way to evaluate their effectiveness.

Question 4 of 5

Which nursing intervention is most appropriate for meeting the needs of an infant with congenital heart disease?

Correct Answer: A

Rationale: Responding quickly to crying minimizes stress and oxygen demand in an infant with congenital heart disease.

Question 5 of 5

The nurse is preparing to perform a sterile dressing change. Which action maintains the sterile field?

Correct Answer: A

Rationale: Opening the sterile kit away from the body prevents contamination of the sterile field.

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