NCLEX-PN
NCLEX Trainer Test 6 Questions
Extract:
Question 1 of 5
A 28-year-old client is admitted to the hospital unit with hepatitis A. The nurse knows that the client's overall care during hospitalization should include which of the following?
Correct Answer: C
Rationale: standard precautions should be used on everyone; sources for this virus are saliva, feces, and blood; use contact isolation if fecal incontinence
Question 2 of 5
After receiving an annual influenza immunization, a client develops symptoms suggestive of Guillain-Barré syndrome. Which symptom is associated with Guillain-Barré syndrome?
Correct Answer: A
Rationale: Guillain-Barré syndrome causes paresthesia and weakness in the lower extremities , progressing upward. Reflexes are hypoactive (B is incorrect). Emotional lability and tremors are not typical.
Question 3 of 5
A client has undergone a lumbar puncture for examination of the CSF. Which of the following findings should be considered abnormal?
Correct Answer: D
Rationale: Elevated white blood cells (100/cu.mm) in CSF suggest infection or inflammation, an abnormal finding. Normal protein, glucose, and clear appearance are expected.
Question 4 of 5
While caring for a child who had a revision of a ventriculoperitoneal shunt, the nurse notes clear drainage from the incision. Which of the following actions should the nurse take first?
Correct Answer: C
Rationale: Clear drainage may indicate cerebrospinal fluid (CSF) leak; checking for glucose with a Dextrostik confirms CSF, which requires immediate action.
Extract:
A client had a radical mastectomy for cancer in her right breast.
Question 5 of 5
After the client returns to the unit, which of the following actions, if performed by the nurse, would be MOST appropriate?
Correct Answer: C
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) sling is not necessary, arm needs to be elevated (2) right arm cannot be elevated from this position (3) correct-this position will facilitate removal of fluid from venous pathways and lymphatic system through gravity; arm is elevated to enhance circulation and prevent edema (4) prone position is not appropriate