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

Questions 157

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Extract:

A 7-year-old daughter weighs 50.25 lb (22.85 kg) and is 48 inches (121.7 cm) tall. The nurse notes that she has gained 2.5 pounds and has grown 3 inches in the past year.


Question 1 of 5

Which of the following responses by the nurse is BEST?

Correct Answer: A

Rationale: Strategy: 'BEST' indicates that you will have to discriminate between answers. The topic of the question is unstated. Read answer choice to obtain clues. (1) correct-between ages 6-12 grows about 2 in (5 cm)/year and gains 4.5-6.5 lb (2-3 kg)/year, at age 7 average 39-66.5 lb (17.7-30 kg) and 44-51 in (111.8-129.7 cm) (2) weight is within normal limits (3) weight is within normal limits (4) height is within normal limits

Extract:


Question 2 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 3 of 5

A client with a T6 injury 6 months ago develops facial flushing and a BP of 210/106. After elevating the head of the bed, which is the most appropriate nursing action?

Correct Answer: B

Rationale: The symptoms suggest autonomic dysreflexia, often triggered by a distended bladder or bowel in clients with spinal cord injuries above T6. Assessing and addressing the trigger, such as a distended bladder, is the most appropriate action. Notifying the RN may be necessary but is not the immediate action, so answer A is incorrect. Oxygen and increased IV fluids do not address the cause, so answers C and D are incorrect.

Question 4 of 5

Which of the following infants is in need of additional growth assessment?

Correct Answer: B

Rationale: Baby B has gained only 1 oz. in 2 weeks, indicating poor growth (normal is 0.5-1 oz./day). Others show appropriate weight gain.

Question 5 of 5

A Hispanic client in the postpartum period refuses the hospital food because it is 'cold.' The best initial action by the nurse is to

Correct Answer: B

Rationale: Ask the client what foods are acceptable or are unacceptable. Understanding cultural food preferences ensures appropriate dietary support.

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