Questions 150

NCLEX-RN

NCLEX-RN Test Bank

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Question 1 of 5

Which clinical manifestations are consistently observed in infants who have been diagnosed with congenital hypothyroidism? Select all that apply.

Correct Answer: B,C,D,F

Rationale: The infant with congenital hypothyroidism may display the following signs: skin mottling, a large fontanel, a large tongue, hypotonia, slow reflexes, bradycardia, and a distended abdomen. Other signs and symptoms include prolonged jaundice, lethargy, constipation, feeding problems, coldness to touch, umbilical hernia, hoarse cry, and excessive sleeping.

Question 2 of 5

The Joint Commission on the Accreditation of Healthcare Organizations mandates standardized 'hand off' change of shift reporting. Which of the following is a standardized 'hand off' change of shift reporting system that you may want to consider for implementation on your nursing care unit?

Correct Answer: C

Rationale: ISBAR is a standardized hand-off reporting system (Introduction, Situation, Background, Assessment, Recommendation) recommended by The Joint Commission for effective communication during shift changes.

Question 3 of 5

The nurse is caring for a client with a chest tube in place for a pneumothorax. Which of the following findings indicates that the chest tube is functioning properly?

Correct Answer: C

Rationale: Fluctuation (tidaling) in the drainage tube with respiration indicates the chest tube is patent and functioning to remove air or fluid.

Question 4 of 5

The nurse is performing routine tracheostomy care. Which of the following steps would be appropriate for the nurse to include in the performance of the procedure?

Correct Answer: B

Rationale: Securing tracheostomy ties with a square knot ensures stability and safety. Frequent cannula removal is unnecessary, cut gauze may fray, and suctioning is done as needed, not routinely.

Question 5 of 5

A therapeutic milieu is:

Correct Answer: D

Rationale: A therapeutic milieu is a structured environment designed to promote healing and recovery through consistency, safety, and therapeutic interactions.

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