NCLEX-PN
NCLEX Trainer Test 4 Questions
Extract:
Question 1 of 5
A client has just returned to the medical-surgical unit following a segmental lung resection. After assessing the client, the first nursing action would be to
Correct Answer: B
Rationale: Suction excessive tracheobronchial secretions. Suctioning the copious tracheobronchial secretions present in post-thoracic surgery clients maintains an open airway, which is always the priority nursing intervention.
Question 2 of 5
The nurse is caring for a client in the coronary care unit. The display on the cardiac monitor indicates ventricular fibrillation. What should the nurse do first?
Correct Answer: C
Rationale: Assess for presence of pulse. Verifying the absence of a pulse confirms ventricular fibrillation before proceeding with treatment.
Question 3 of 5
An adult who was struck by lightning is brought to the emergency department. Which action is of highest priority when the client is brought to the emergency room?
Correct Answer: A
Rationale: Lightning strikes can cause cardiac arrhythmias; obtaining an ECG is the highest priority to detect life-threatening rhythm disturbances. Gases, wounds, and electrolytes are secondary.
Extract:
A 25-year-old woman after a vaginal delivery.
Question 4 of 5
Which of the following is the FIRST nursing action that should be implemented for a 25-year-old woman after a vaginal delivery?
Correct Answer: A
Rationale: Strategy: 'FIRST' indicates that this is a priority question. Remember the ABCs. (1) correct-complication of hemorrhage assessed by observing lochial flow (2) done to assist its natural clamping-down action, assessed as firm or boggy (3) must meet physical needs first (4) not first action, hemorrhage most important complication
Extract:
Question 5 of 5
The nurse is preparing a five-year-old child for surgery.
Correct Answer: D
Rationale: In cases of joint legal custody, consent from either parent is sufficient for surgical procedures. Since the mother has signed the informed consent, no further action is needed, and the nurse should continue preoperative preparation. Notifying the physician, informing surgery, or contacting the father is unnecessary.