NCLEX Questions, NCLEX PN Practice Test Questions, NCLEX-PN Questions, Nurselytic

Questions 164

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Extract:


Question 1 of 5

While caring for a woman who delivered a healthy term infant six hours ago, the nurse notes that the fundus is soft, 2 cm above the umbilicus, and off to the left. The lochia is red. The nurse suspects that the client has which problem?

Correct Answer: C

Rationale: A soft, displaced fundus suggests urinary retention, causing bladder pressure on the uterus. Normal involution shows a firm, midline fundus; fragments or lacerations present differently.

Extract:

Laboratory results
Hematocrit
Male: 42%–52%
(0.42-0.52)

Female: 37%–47%
(0.37–0.47) 30%
(0.30)
Activated PTT
Baseline: 30–40 sec 110 sec
Platelets
150,000–400,000/mm3
(150–400 × 109/L) 80,000/mm3
(80 x 109/L)
PT
11–12.5 sec 11 sec


Question 2 of 5

The nurse is reinforcing teaching for a client who is prescribed acyclovir for genital herpes. Which statement should be included by the nurse?

Correct Answer: A

Rationale: Heparin is an anticoagulant that helps prevent further clot formation. It is titrated based on activated partial
thromboplastin time (aPTT). The therapeutic aPTT target is 1.5-2.0 times the normal reference range of 30-40
seconds. A aPTT value >100 seconds would be considered critical and could result in life-threatening side
effects. Common sentinel events that result from heparin drips include epistaxis, hematuria, and gastrointestina
bleeds (Option 1).
(Option 2) A normal hematocrit for a female is 37%-47% (0.37-0.47). In a client with a history of chronic
anemia, a hematocrit of 30% (0.30) may be an expected finding.
(Option 3) A normal platelet count is 150,000-400,000/mm* (150-400 x 10%L). In a client with a history of liver
cirrhosis, a platelet count of 80,000/mmª (80 x 10%/L) would be anticipated. An episode of bleeding rarely occurs
with a platelet count >50,000 mm* (50 x 10%/L).
(Option 4) A normal prothrombin time is 11-12.5 seconds, and so a level of 11 seconds would not be
concerning.

Extract:


Question 3 of 5

At a nursing staff meeting, there is discussion of perceived inequities in weekend staff assignments. As a follow-up, the nurse manager should initially

Correct Answer: D

Rationale: Facilitate creative thinking on staffing. The 'moving phase' of change involves viewing the problem from a new perspective, and then incorporating new and different approaches to the problem. The manager, as a change agent, can facilitate staff's solving the problem.

Question 4 of 5

During an initial prenatal visit, the practical nurse is reviewing the history of a client at 10 weeks gestation. Which finding is a priority to report to the registered nurse?

Correct Answer: A

Rationale: Pet cats (
A) pose a toxoplasmosis risk, which can cause fetal harm, requiring immediate education and possible testing. Weight gain (
B) is normal, milky discharge (
C) is typical in pregnancy, and swimming (
D) is safe.

Extract:

Laboratory results
WBC
5000-10,000/mm³
(5-10 × 10⁹/L) 1400/mm3
(1.4 × 109/L)
Hemoglobin
Male: 14-18 g/dL
(140-180 g/L)

Female: 12-16 g/dL
(120-160 g/L) 10 g/dL
(100 g/L)
Absolute neutrophil count
2500-8000/mm³
(2.5-8 × 10⁹/L) 500/mm3
(0.5 × 109/L)
Potassium
3.5-5.0 mEq/L
(3.5-5.0 mmol/L) 3.4 mEq/L
(3.4 mmol/L)
Platelets
150,000-400,000/mm³
(150-400 × 10⁹/L) 150,000/mm3
(150 × 109/L)


Question 5 of 5

A client in the hospital is receiving chemotherapy. Based on today’s blood laboratory results, which of the following actions should the nurse take?

Correct Answer: D

Rationale: Chemotherapy often causes neutropenia, increasing infection risk. A face mask (
D) protects the client. Hematuria (
A), peaked T waves (
B), and epoetin (
C) address other issues not directly indicated.

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