NCLEX-PN
NCLEX Trainer Test 3 Questions
Extract:
Question 1 of 5
A client has a repair of a hiatal hernia using a thoracic approach. During the immediate post-op period, the nurse should carefully assess the client for:
Correct Answer: B
Rationale: A thoracic approach affects the chest, so respiratory changes (e.g., distress, decreased oxygen saturation) are critical to assess post-op. Appetite, anxiety, and activity intolerance are less immediate concerns.
Question 2 of 5
The nurse is performing a physical assessment on a client with insulin dependent diabetes mellitus. Which client finding calls for immediate nursing action?
Correct Answer: A
Rationale: Diaphoresis and shakiness. Diaphoresis is a sign of hypoglycemia, which warrants immediate attention to prevent severe complications.
Question 3 of 5
The nurse is caring for a client with a history of schizophrenia.
Correct Answer: B
Rationale: Improved ability to focus on tasks indicates reduced psychotic symptoms and better cognitive function, a positive response to antipsychotics. Withdrawal, hallucinations, and agitation suggest poor response.
Question 4 of 5
The nurse is assessing a client with suspected appendicitis.
Correct Answer: B
Rationale: Positive rebound tenderness at McBurney’s point is a hallmark of appendicitis, indicating peritoneal irritation. Supine positioning may worsen pain, absent bowel sounds suggest obstruction, and a normal WBC count does not rule out appendicitis.
Extract:
A client has a nasogastric tube in place after extensive abdominal surgery. The client complains of nausea. His abdomen is distended, and there are no bowel sounds.
Question 5 of 5
The FIRST nursing action should be to
Correct Answer: C
Rationale: Strategy: Answers are a mix of assessments and implementations. Is this a situation that requires assessment? Yes. (1) implementation, may be carried out after the patency of the tube is determined (2) implementation, patency should be checked first (3) correct-should first assess if the tube is open and draining to determine if there is a problem with the nasogastric tube; if it is patent and draining it does not need to be irrigated (4) assessment, patency should be checked first by aspirating stomach contents, not by auscultation