NCLEX-PN
NCLEX Trainer Test 2 Questions
Extract:
Question 1 of 5
A client on assisted ventilation develops a right-sided tension pneumothorax. Which of the following signs is associated with a right-sided tension pneumothorax?
Correct Answer: A
Rationale: Tension pneumothorax causes lung collapse, reducing breath sounds on the affected side (right). Tracheal deviation is toward the unaffected side (left).
Extract:
A client is diagnosed with lung cancer and undergoes a pneumonectomy.
Question 2 of 5
In the immediate postoperative period, which of the following nursing assessments is MOST important?
Correct Answer: B
Rationale: Strategy: Determine how each answer choice relates to a pneumonectomy. (1) on the surgical side, breath sounds will be absent (2) correct-position of the trachea should be evaluated; with a tracheal shift, an increase in pressure could occur on the operative side and could cause pressure against the mediastinal area (3) important to observe but not as high a priority (4) does not relate to the situation
Extract:
Question 3 of 5
The physician has ordered a low-magnesium diet for a client with end-stage renal failure. Which of the following diet selections should be removed from the client's meal tray?
Correct Answer: B
Rationale: Spinach is high in magnesium, which should be restricted in end-stage renal failure due to impaired excretion. Fruit compote , baked potato , and custard are lower in magnesium.
Question 4 of 5
The newborn infant of an HIV-positive mother is admitted to the nursery.
Correct Answer: A
Rationale: Standard precautions are the immediate priority to protect staff and others from potential HIV transmission. HIV Test ing and AZT may be considered later, and transfer is unnecessary without clinical indication.
Question 5 of 5
The nurse is assessing the mental status of a client admitted with possible organic brain disorder. Which of these questions will best assess the functioning of the client's recent memory?
Correct Answer: C
Rationale: I am going to say the names of three things and I want you to repeat them after me: blue, ball, pen. This tests immediate recall, a component of recent memory.