NCLEX-PN Exam Questions - Part 133

1. A patient has suffered a left CVA and has developed severe hemiparesis resulting in a loss of mobility. The nurse notices on assessment that an area over the patients left elbow appears as non-blanchable erythema and the skin is intact. The nurse should score the patient as having which of the following?

A) Stage I pressure ulcer
B) Stage II pressure ulcer
C) Stage III pressure ulcer
D) Stage IV pressure ulcer



2. A newborn baby exhibits a reflex that includes: hand opening, abducted and extended extremities following a jarring motion. Which of the following correctly identifies the reflex?

A) ATNR reflex
B) Startle reflex
C) Grasping reflex
D) Moro reflex



3. A mother that has never breast-feed a child before is having trouble getting the baby to latch on to the breast. The baby has lost 3% of its birth weight within the first 2 days of life. The best statement is:

A) The baby will eventually take to the breast.
B) I can fix up a bottle if you want to try that.
C) A small amount of weight loss in the first few days is normal.
D) I can get the charge nurse to come and talk to you about breast-feeding.



4. A nurse suspects a patient is developing Bells Palsy. The nurse wants to test the function of cranial nerve VII. Which of the following would be the most appropriate testing procedures?

A) Test the taste sensation over the back of the tongue and activation of the facial muscles.
B) Test the taste sensation over the front of the tongue and activation of the facial muscles.
C) Test the sensation of the facial muscles and sensation of the back of the tongue.
D) Test the sensation of the facial muscles and sensation of the front of the tongue.



5. A patient has a history of cardiac arrhythmia. A nurse has been ordered to give 2 units of blood to this patient. The nurse should take which of the following actions?

A) Prep the patient with pain medication.
B) Notify the patient - s family about the procedure via the telephone.
C) Decrease the temperature of the blood to be given.
D) Increase the temperature of the blood to be given.