NCLEX Questions, NCLEX Trainer Test 1 Questions, NCLEX-PN Questions, Nurselytic

Questions 157

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Extract:


Question 1 of 5

The nurse is caring for a neonate with an infection. The nurse would be MOST concerned if which of the following was observed?

Correct Answer: D

Rationale: A respiratory rate of 65 at rest (normal 30–50) indicates tachypnea, suggesting sepsis or hypoxia. Options A, B, and C are less concerning.

Question 2 of 5

The nurse is to start oxygen therapy via nasal cannula. Which action is correct?

Correct Answer: D

Rationale: Inserting the cannula 1 cm into the nostrils ensures proper oxygen delivery. High flow rates, petrolatum, or mask pre-oxygenation are incorrect.

Question 3 of 5

The nurse is caring for a client with a history of atrial fibrillation who is receiving digoxin (Lanoxin) 0.125 mg PO daily. Which of the following laboratory results would be of GREATest concern to the nurse?

Correct Answer: A

Rationale: Hypokalemia (potassium 3.0 mEq/L) increases the risk of digoxin toxicity, which can cause life-threatening arrhythmias in atrial fibrillation. Options B, C, and D are normal: sodium 140 mEq/L, magnesium 2.0 mEq/L, and calcium 9.0 mg/dL do not affect digoxin.

Question 4 of 5

A client hospitalized with acute glomerulonephritis has a positive ASO titer. The nurse understands that the client's current illness is due to a:

Correct Answer: B

Rationale: A positive antistreptolysin titer indicates infection with Group A β-hemolytic Streptococcus, a bacterial infection. Answers A, C, and D are not associated with acute glomerulonephritis so they are incorrect.

Extract:

A client that has stage III pressure ulcer of the sacrum with foul smelling purulent drainage.


Question 5 of 5

The nurse should intervene in which of the following situations?

Correct Answer: B

Rationale: Strategy: 'Nurse should intervene' indicates an incorrect behavior. All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) contact precautions required for infected decubitus ulcer; private room if possible (2) correct-masks not needed and doors do not need to be closed (3) maintain positive nitrogen balance, should offer high protein diet with protein supplements (4) lifting prevents shearing force

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