NCLEX-PN
NCLEX Trainer Test 3 Questions
Extract:
Question 1 of 5
A client has just been admitted with portal hypertension. Which nursing diagnosis would be a priority in planning care?
Correct Answer: B
Rationale: Potential complication hemorrhage. Esophageal varices are dilated and tortuous vessels of the esophagus that are at high risk for rupture if portal circulation pressures rise.
Question 2 of 5
A wet-to-dry dressing is ordered for a client who has a decubitus ulcer. Which technique is appropriate?
Correct Answer: C
Rationale: Wet-to-dry dressings involve a moist gauze applied to the wound, covered with dry gauze, to debride tissue as it dries. Other techniques are incorrect.
Question 3 of 5
The physician's orders include warm compresses to the left leg three times a day for treatment of an open wound. Which action is appropriate when carrying out these orders?
Correct Answer: C
Rationale: A dry covering and waterproof material over the compress maintain warmth and prevent contamination while keeping the surrounding area dry. Aseptic technique is needed for open wounds, open-air compresses lose heat, and five minutes is too short.
Question 4 of 5
A young child with a history of grand mal seizures is in public school. He is on phenobarbital and hydantoin (Dilantin) to control the seizures. His teacher tells the nurse that he has not had any seizures but he does keep falling asleep in class. What should the nurse include when discussing his drowsiness with the teacher?
Correct Answer: A
Rationale: Phenobarbital, a barbiturate, commonly causes drowsiness, explaining the child's sleepiness in class, which should be monitored but is expected.
Question 5 of 5
An adult who is receiving methotrexate for rheumatoid arthritis asks the nurse why she is receiving methotrexate. What should the nurse include when responding?
Correct Answer: C
Rationale: Methotrexate suppresses the autoimmune response in rheumatoid arthritis, reducing joint inflammation and damage. It is not primarily for pain, fever, or cartilage repair.