NCLEX-PN
NCLEX Trainer Test 7 Questions
Extract:
Question 1 of 5
A client with a fractured femur has been in Russell's traction for 24 hours. Which nursing action is associated with this therapy?
Correct Answer: D
Rationale: Perform a neurovascular check for circulation. While each of these is an important assessment, the neurovascular integrity check is most associated with this type of traction. Russell's traction is Buck's traction with a sling under the knee.
Question 2 of 5
The nurse is caring for a client admitted to the hospital with right lower lobe (RLL) pneumonia. On assessment, the nurse notes crackles over the RLL. The client has significant pleuritic pain and is unable to take in a deep breath in order to cough effectively. Which nursing diagnosis would be most appropriate for this client based on this assessment data?
Correct Answer: B
Rationale: Ineffective airway clearance is defined as the inability to cough effectively, directly supported by the assessment data of crackles and ineffective cough.
Question 3 of 5
The home care nurse has been managing a client for 6 weeks. What is the best method to determine the quality of care provided by a home health care aide assigned to assist with the care of this client?
Correct Answer: B
Rationale: Although the nurse must complete all of the above responsibilities, evaluation of an adherence to the plan of care is the first priority. The plan of care is based on the reason for referral, provider's orders, the initial nursing assessment, the client's responses to the planned interventions, and the client's and family's feedback or inquiries.
Question 4 of 5
The client has just had a basal cell carcinoma removed in the doctor's office. Which statement the client makes indicates understanding regarding prevention and early detection of basal cell carcinoma?
Correct Answer: B
Rationale: Long sleeves protect against UV exposure, a key risk for basal cell carcinoma. Moles, lotions, or tanning booths are unrelated or harmful.
Question 5 of 5
The nurse is caring for a client who is postoperative day 1 after a coronary artery bypass graft (CABG). Which of the following findings should the nurse report immediately?
Correct Answer: B
Rationale: A temperature of 100.8°F suggests infection, a serious post-CABG complication. Options A, C, and D are normal or expected.