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Questions 160

NCLEX-PN

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Extract:


Question 1 of 5

The nurse is caring for a client with a urinary catheter. Which action reduces the risk of catheter-associated urinary tract infection?

Correct Answer: B

Rationale: Daily cleaning of the catheter insertion site with soap and water reduces bacterial growth and infection risk.

Question 2 of 5

Which nursing action best determines if a client has a fecal impaction?

Correct Answer: D

Rationale: A digital rectal exam directly confirms the presence of hard, impacted stool in the rectum.

Question 3 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 4 of 5

A client with a history of breast cancer is receiving tamoxifen. Which side effect should the nurse monitor for?

Correct Answer: A

Rationale: Hot flashes are a common side effect of tamoxifen due to its anti-estrogenic effects.

Question 5 of 5

Which of the following clients is at the greatest risk of developing maternal and fetal complications during pregnancy? Select all that apply.

Correct Answer: A,D,E

Rationale: Restricting food intake can lead to malnutrition, increasing fetal risks. Advanced maternal age (36) increases complications like gestational diabetes. Refusing prenatal vitamins can cause deficiencies, affecting fetal development.

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