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NCLEX-PN Exam Questions - Part 119
1. A primigravida begins labor when her family is unavailable and she is alone. She is very upset that her family is not with her. Which approach can the nurse take to meet the clients needs at this time?
A) asking whether another individual wants to be her support person
B) assuring her that the nursing triage group will be with her at all times
C) telling her you will try to locate her family
D) reinforcing the woman - s confidence in her own abilities to cope and maintain a sense of control
2. Signs of internal bleeding include all of the following except:
A) painful or swollen extremities.
B) a tender, rigid abdomen.
C) vomiting bile.
D) bruising.
3. A newborn has been delivered. An Apgar score is given. What does this scoring system indicate?
A) heart rate, respiratory effort, color, muscle tone, reflex irritability
B) heart rate, bleeding, cyanosis, edema
C) bleeding, reflex, edema
D) respiratory effort, heart rate, seizures
4. The nurse working with elderly clients should keep in mind that falls are most likely to happen to elderly who are:
A) in their 80s.
B) living at home.
C) hospitalized.
D) living on only Social Security income.
5. The nurse assesses a client for physiological risk factors for falls. The nurse should conclude that the client is not at risk if which of the following is discovered?
A) history of dizziness
B) need for wheelchair due to reduced mobility
C) weakness and fatigue noted when climbing stairs
D) intact recent and remote memory
A) asking whether another individual wants to be her support person
B) assuring her that the nursing triage group will be with her at all times
C) telling her you will try to locate her family
D) reinforcing the woman - s confidence in her own abilities to cope and maintain a sense of control
2. Signs of internal bleeding include all of the following except:
A) painful or swollen extremities.
B) a tender, rigid abdomen.
C) vomiting bile.
D) bruising.
3. A newborn has been delivered. An Apgar score is given. What does this scoring system indicate?
A) heart rate, respiratory effort, color, muscle tone, reflex irritability
B) heart rate, bleeding, cyanosis, edema
C) bleeding, reflex, edema
D) respiratory effort, heart rate, seizures
4. The nurse working with elderly clients should keep in mind that falls are most likely to happen to elderly who are:
A) in their 80s.
B) living at home.
C) hospitalized.
D) living on only Social Security income.
5. The nurse assesses a client for physiological risk factors for falls. The nurse should conclude that the client is not at risk if which of the following is discovered?
A) history of dizziness
B) need for wheelchair due to reduced mobility
C) weakness and fatigue noted when climbing stairs
D) intact recent and remote memory
1. Right Answer: A
Explanation: Allow the client to select another individual to give support. This allows her to have someone with her until her family can be with her. Safety and Infection Control
2. Right Answer: C
Explanation: Vomiting bile is usually not a sign of internal bleeding. Signs of internal bleeding include painful or swollen extremities; a tender, rigid abdomen; and bruising.Safety and Infection Control
3. Right Answer: A
Explanation: The Apgar scoring system was put into place by Virginia Apgar, an anesthesiologist in New York, for the purpose of assessing newborns in the areas of heart rate, respiratory effort, color, muscle tone, and reflex irritability at 1, 5, and sometimes 10 minutes after birth. Safety and Infection Control
4. Right Answer: C
Explanation: Elder people are particularly prone to falling and incurring serious injury, especially in new situations and environments (such as the hospital). Safety and InfectionControl
5. Right Answer: D
Explanation: Intact recent and remote memory indicates that a client is not at risk for falls. Risk for falls can occur in elder clients, and the nurse should assess each client for the possibility of falls and take appropriate actions. Safety and Infection Control
Explanation: Allow the client to select another individual to give support. This allows her to have someone with her until her family can be with her. Safety and Infection Control
2. Right Answer: C
Explanation: Vomiting bile is usually not a sign of internal bleeding. Signs of internal bleeding include painful or swollen extremities; a tender, rigid abdomen; and bruising.Safety and Infection Control
3. Right Answer: A
Explanation: The Apgar scoring system was put into place by Virginia Apgar, an anesthesiologist in New York, for the purpose of assessing newborns in the areas of heart rate, respiratory effort, color, muscle tone, and reflex irritability at 1, 5, and sometimes 10 minutes after birth. Safety and Infection Control
4. Right Answer: C
Explanation: Elder people are particularly prone to falling and incurring serious injury, especially in new situations and environments (such as the hospital). Safety and InfectionControl
5. Right Answer: D
Explanation: Intact recent and remote memory indicates that a client is not at risk for falls. Risk for falls can occur in elder clients, and the nurse should assess each client for the possibility of falls and take appropriate actions. Safety and Infection Control
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