NCLEX-PN
NCLEX Trainer Test 2 Questions
Extract:
Question 1 of 5
A client who is withdrawing from alcohol says to the nurse, 'There are snakes on the wall.' Which action should the nurse take initially?
Correct Answer: C
Rationale: Acknowledging the hallucination (delirium tremens) as perceived but clarifying reality reduces agitation without confrontation. Reassurance or lighting changes are less effective.
Extract:
A postoperative appendectomy client who is complaining of incisional pain. A diabetic client who had a cardiac catheterization in the early AM. A postoperative cholecystectomy client who is complaining of incisional pain. A client with congestive heart failure who underwent diuresis in the hospital.
Question 2 of 5
The nurse is planning discharge for a group of clients. It is MOST important to refer which of the following clients for home care?
Correct Answer: D
Rationale: Strategy: Determine the least stable client. Remember the ABCs. (1) expected outcome, treat with analgesics (2) instruct no bending, straining, or lifting heavy objects for 24 hours, observe for bleeding, swelling, new bruising at puncture site (3) expected outcome, treat with analgesics (4) correct-assess for decreased circulating volume, hypotension, tachycardia, monitor for signs and symptoms of hypokalemia
Extract:
Question 3 of 5
In addition to standard precautions, a nurse should implement contact precautions for which client?
Correct Answer: A
Rationale: 60 year-old with herpes simplex. Clients who have herpes simplex infections must have contact precautions in addition to standard precautions because of the associated, potentially weeping, skin lesions. Contact precautions are used for clients who are infected by microorganisms that are transmitted by direct contact with the client, including hand or skin-to-skin contact.
Question 4 of 5
The nurse is caring for a 14-year-old girl admitted with an acute exacerbation of ulcerative colitis.
Correct Answer: D
Rationale: Involving the adolescent in planning her daily schedule promotes autonomy and control, which is developmentally appropriate and therapeutic for managing chronic illness. Rooming in, school programs, and friend visits are supportive but less empowering for self-management.
Question 5 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.