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Questions 227

NCLEX-PN

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Question 1 of 5

The nurse is performing a developmental assessment on an 8 month-old. Which finding should be reported to the provider?

Correct Answer: D

Rationale: Falls forward when sitting. Sitting without support is expected at 8 months, indicating a developmental concern.

Question 2 of 5

While writing a report at 3:15 in the afternoon, the nurse realizes that she forgot to chart the client's physical therapy, which occurred at 10:30 A.M. Which is the appropriate action for the nurse to take?

Correct Answer: B

Rationale: A late entry with the correct time (10:30 A.M.) ensures accurate documentation, maintaining the integrity of the medical record.

Question 3 of 5

The doctor has ordered a stool specimen for culture. When collecting a stool specimen, the nurse should:

Correct Answer: A

Rationale: Extracting from the center ensures a representative sample for culture. Other methods risk contamination or improper handling.

Question 4 of 5

A client with paranoid personality disorder monopolizes group activities with complaints that the staff is out to get him. The nurse should:

Correct Answer: D

Rationale: One of the most therapeutic actions the nurse can take with the paranoid client is to spend time with him but not challenge his delusions. Answer A would challenge his delusions and make him more convinced that he is right, so it is incorrect. Answers B and C would isolate the client and increase his paranoid thinking, so they're incorrect.

Question 5 of 5

The nurse is assessing a client with a history of heart failure. Which of the following findings would indicate worsening heart failure?

Correct Answer: A

Rationale: Weight gain of 2 kg in 24 hours indicates fluid retention, a sign of worsening heart failure due to decreased cardiac output. Normal blood pressure (
B), heart rate (
C), and clear lungs (
D) do not suggest decompensation.

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