NCLEX-PN
NCLEX Trainer Test 1 Questions
Extract:
Question 1 of 5
A client with a T6 injury 6 months ago develops facial flushing and a BP of 210/106. After elevating the head of the bed, which is the most appropriate nursing action?
Correct Answer: B
Rationale: The symptoms suggest autonomic dysreflexia, often triggered by a distended bladder or bowel in clients with spinal cord injuries above T6. Assessing and addressing the trigger, such as a distended bladder, is the most appropriate action. Notifying the RN may be necessary but is not the immediate action, so answer A is incorrect. Oxygen and increased IV fluids do not address the cause, so answers C and D are incorrect.
Question 2 of 5
A client with chronic bronchitis is admitted with complaints of chest pain. Which of the following drug orders should the nurse question?
Correct Answer: C
Rationale: Propranolol, a beta-blocker, can exacerbate bronchoconstriction in chronic bronchitis, worsening respiratory symptoms. Nitroglycerin, cephalexin, and verapamil are less likely to pose issues in this context.
Question 3 of 5
The mother of a 2-month-old child asks the nurse when she should start her son on solids. He is taking about 30 oz of formula per day. How should the nurse respond?
Correct Answer: C
Rationale: Solids are typically introduced between 4-6 months when infants have better head control and digestive maturity, not at 2 months or based on formula volume.
Extract:
A client experiencing hallucinations.
Question 4 of 5
Which of the following behaviors by a client should the nurse record to indicate that the client is experiencing hallucinations?
Correct Answer: B
Rationale: Strategy: Think about each answer choice. (1) describes behavior associated with depression (2) correct-hallucinations are sensory perceptions for which there is no external stimulus; this option describes client behavior that would be observed when the client is responding to voices (3) describes behavior associated with delusional thinking (4) describes behavior most associated with anxiety
Extract:
A 7-year-old daughter weighs 50.25 lb (22.85 kg) and is 48 inches (121.7 cm) tall. The nurse notes that she has gained 2.5 pounds and has grown 3 inches in the past year.
Question 5 of 5
Which of the following responses by the nurse is BEST?
Correct Answer: A
Rationale: Strategy: 'BEST' indicates that you will have to discriminate between answers. The topic of the question is unstated. Read answer choice to obtain clues. (1) correct-between ages 6-12 grows about 2 in (5 cm)/year and gains 4.5-6.5 lb (2-3 kg)/year, at age 7 average 39-66.5 lb (17.7-30 kg) and 44-51 in (111.8-129.7 cm) (2) weight is within normal limits (3) weight is within normal limits (4) height is within normal limits