NCLEX-PN
NCLEX Trainer Test 10 Questions
Extract:
Question 1 of 5
A client is admitted with a fractured right hip. The doctor writes an order for Buck's traction. Which of the following actions, if taken by the nurse, is MOST important?
Correct Answer: A
Rationale: immobility is a leading cause of problems with Buck's traction; important to turn client to unaffected side
Question 2 of 5
Which of the following nursing actions has the HIGHEST priority for a teenager admitted with burns to 50% of his body?
Correct Answer: C
Rationale: A teenager with 50% body burns is at high risk for infection due to loss of skin barrier. Maintaining aseptic technique during procedures is the highest priority to prevent life-threatening infections. Counseling, precautions, and peer visits are important but secondary to infection control.
Question 3 of 5
The nurse is preparing to administer digoxin (Lanoxin) to a client. The client's apical pulse is 56 beats per minute. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: digoxin is held if the apical pulse is below 60 beats per minute in adults to prevent toxicity
Question 4 of 5
An 8-year-old boy is brought to the physician’s office by his mother. The mother is concerned because the boy has a fever, vomited twice, and slept all day yesterday with the curtains closed. The boy complains of headache, nausea, and has a temperature of 103°F (39.3°C). The nurse observes the boy has a petechial rash on the trunk of his body. Which of the following assessments would be MOST important for the nurse to perform?
Correct Answer: C
Rationale: Fever, headache, nausea, and petechial rash suggest meningitis; flexing the neck (Brudzinski’s sign) assesses meningeal irritation, a priority. Options A, B, and D are less relevant: hand squeeze is nonspecific, Babinski’s sign is not indicated, and Romberg’s sign assesses balance.
Question 5 of 5
The nurse is caring for a 22-year-old woman who is completing the first stage of labor. The woman's husband is at her side and has been coaching her according to exercises they learned at natural childbirth classes. Suddenly the woman begins to shake and screams, 'I can't stand this anymore!' The nurse should encourage the husband to
Correct Answer: A
Rationale: entering transition phase of first stage of labor, slow shallow breaths needed (pant breathing)