NCLEX-PN
NCLEX Trainer Test 6 Questions
Extract:
Question 1 of 5
A client was admitted to the psychiatric unit after complaining to her friends and family that neighbors have bugged her home in order to hear all of her business. She remains aloof from other clients, paces the floor and believes that the hospital is a house of torture. Nursing interventions for the client should appropriately focus on efforts to
Correct Answer: C
Rationale: Provide interactions to help the client learn to trust staff. Establishing trust helps clients feel safer and facilitates a therapeutic alliance between staff and client.
Question 2 of 5
While caring for a child who had a revision of a ventriculoperitoneal shunt, the nurse notes clear drainage from the incision. Which of the following actions should the nurse take first?
Correct Answer: C
Rationale: Clear drainage may indicate cerebrospinal fluid (CSF) leak; checking for glucose with a Dextrostik confirms CSF, which requires immediate action.
Extract:
Before administering calcium gluconate 10% 500 mg IV stat.
Question 3 of 5
It is MOST important that the nurse assess the
Correct Answer: C
Rationale: Strategy: Determine how each answer choice relates to calcium gluconate. (1) unnecessary in this situation (2) unnecessary in this situation (3) correct-if injected into the extravascular tissues, calcium gluconate can cause a severe chemical burn (4) irrelevant
Extract:
Question 4 of 5
A client has undergone a lumbar puncture for examination of the CSF. Which of the following findings should be considered abnormal?
Correct Answer: D
Rationale: Elevated white blood cells (100/cu.mm) in CSF suggest infection or inflammation, an abnormal finding. Normal protein, glucose, and clear appearance are expected.
Question 5 of 5
A child is admitted with acute glomerulonephritis. Which finding in the client's history is most consistent with the diagnosis?
Correct Answer: B
Rationale: Acute glomerulonephritis is often post-streptococcal, following pharyngitis by 1-3 weeks, due to immune complex deposition in glomeruli. Tick bites, mosquito bites, or uric acid are unrelated.