NCLEX-PN
NCLEX Trainer Test 6 Questions
Extract:
Question 1 of 5
A 78-year-old client is admitted in heart failure. Which assessment is essential for the nurse to make because the client is in heart failure? Select all that apply.
Correct Answer: B,D,E
Rationale: Persons who are in heart failure are at risk for developing pulmonary edema. The nurse should listen for lung sounds, check legs for pitting edema, which is common in heart failure, and observe respirations for severe dyspnea. Pedal pulses, upper extremity neuro checks, and gait disturbances are not related to heart failure or to pulmonary edema.
Question 2 of 5
A high school nurse observes a 14 year-old female rubbing her scalp excessively in the gym. The most appropriate course of action for the nurse to do is:
Correct Answer: C
Rationale: Observation of the student's hair is the next step.
Question 3 of 5
The nurse is caring for a client who was in a motor vehicle accident. His blood pressure is dropping rapidly. What should the nurse observe the client for before placing the client in shock position?
Correct Answer: C
Rationale: Shock position (legs elevated) is contraindicated in head injury due to increased intracranial pressure risk. Observing for head injury ensures safety before positioning.
Question 4 of 5
A young adult patient constantly seeks attention from the nurses, stomping away from the nurses’ station and pouting when her requests are refused.
Correct Answer: B
Rationale: Rewarding non-attention-seeking behaviors with unsolicited attention reinforces positive behavior. Ignoring the patient or rotating staff does not address the behavior constructively, and assigning one staff member reduces consistency in approach.
Extract:
A client with hyperthyroidism.
Question 5 of 5
Which of the following actions, if taken by the nurse, is BEST?
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) client is usually sensitive to heat (2) correct-clients with hyperthyroidism frequently exhibit exophthalmos, which requires ophthalmic drops on a regular basis (3) should provide a calm, restful environment with low levels of sensory stimulation, protecting eyes from injury takes priority (4) frequent snacks should be high-calorie