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Questions 160

NCLEX-PN

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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

A non-English-speaking Hispanic client is admitted to the hospital to rule out myocardial infarction. The nurse performs a cultural assessment. Which information should be included? Select all that apply.

Correct Answer: A,C,E,F

Rationale: Food preferences, primary language, religion, and pain status are relevant for culturally sensitive care and effective communication.

Question 3 of 5

Which assessment finding provides the best evidence that a client remains adequately oxygenated while a tracheostomy is suctioned?

Correct Answer: C

Rationale: Remaining alert during suctioning indicates adequate oxygenation, as hypoxia would cause altered mental status.

Question 4 of 5

A client with a history of depression is prescribed sertraline (Zoloft). Which side effect should the nurse monitor for?

Correct Answer: B

Rationale: Insomnia is a common side effect of sertraline, a selective serotonin reuptake inhibitor.

Question 5 of 5

After assessing the client, the nurse initiates the process for reporting the client's STI to the state health agency. Which client has the STI that the nurse is reporting?

Correct Answer: B

Rationale: A. This illustrates acne vulgaris, which is not an STI. B. This illustrates herpes. While herpes simplex may not necessarily be state reportable, it is an STI. By state law, the incidence of some STIs must be reported to the state. C. This illustrates a contact dermatitis; in this client it was caused by nail polish. D. This illustrates candidiasis or thrush. This is not reportable.

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