NCLEX-PN
NCLEX Trainer Test 4 Questions
Extract:
Question 1 of 5
A clear liquid diet is ordered for an adult following surgery. All of the following are on the client's tray. Which should be removed by the nurse?
Correct Answer: A
Rationale: Ice cream is not a clear liquid, as it contains dairy solids, and must be removed from a clear liquid diet tray.
Question 2 of 5
The nurse is providing home care to a confused older adult. The family members have tied the client in a chair with a large leather belt. They say the client wanders if he isn't restrained. What initial nursing action is most appropriate?
Correct Answer: C
Rationale: Helping the family create a safer environment addresses wandering non-restrictively, promoting safety and autonomy. Reporting, praising, or prohibiting are less constructive.
Question 3 of 5
The nurse is performing a post-op assessment of an elderly client with a total hip repair. Although he has not requested medication for pain, the nurse suspects that the client's discomfort is severe and prepares to administer pain medication. Which of the following signs would not support the nurse's assessment of acute post-op pain?
Correct Answer: D
Rationale: Acute pain typically increases heart rate, blood pressure, and pupil dilation. Decreased heart rate is not consistent with acute pain.
Question 4 of 5
A 70-year-old man with a history of hypertension and closed-angle glaucoma visits the clinic for a routine check-up. Which of the following medications, if ordered by the physician, should the nurse question?
Correct Answer: C
Rationale: contraindicated; ophthalmic vasoconstrictor, contraindicated with closed angle glaucoma; use cautiously with hypertension
Question 5 of 5
The nurse is evaluating the progress of a client who has had a cerebrovascular accident and realizes there has been limited progress. What should the nurse do?
Correct Answer: B
Rationale: Reassessing goals adjusts the care plan to the client's current abilities, optimizing recovery post-CVA.