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
A client arrives in the emergency department after a radiologic accident at a local factory. The first action of the nurse would be to
Correct Answer: B
Rationale: The nurse must initially assist in stabilizing the patient prior to performing the other tasks related to radiologic contamination.
Question 3 of 5
A client with angina is experiencing migraine headaches. The physician has prescribed sumatriptan succinate (Imitrex). Which nursing action is most appropriate?
Correct Answer: A
Rationale: Sumatriptan is contraindicated in clients with angina due to its vasoconstrictive effects, which could exacerbate cardiac ischemia. Consulting the RN to verify the order is the most appropriate action. Obtaining samples, discharge teaching, or consulting social services do not address the safety concern, so answers B, C, and D are incorrect.
Extract:
A client has been transferred from a nursing home to the hospital with an indwelling urinary catheter. The urine is cloudy and foul-smelling.
Question 4 of 5
Which of the following nursing measures would be MOST appropriate?
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) does not address the problem of the client's urine, should not be performed (2) correct-increasing intake of fluids is an appropriate independent nursing action that facilitates removal of concentrated urine (3) does not address the problem of the client's urine, should not be performed (4) could increase the chance of developing an infection
Extract:
Question 5 of 5
A client hospitalized with bipolar disorder, manic phase, begins to talk loudly, pace the floor, and shout commands to others in the day room as he quickly changes the TV channels. The nurse's first action should include:
Correct Answer: B
Rationale: Escorting the client from the day room de-escalates the situation by removing them from a stimulating environment, reducing agitation.