NCLEX-PN
NCLEX Trainer Test 2 Questions
Extract:
Question 1 of 5
A client with asthma has low pitched wheezes present on the final half of exhalation. One hour later the client has high pitched wheezes extending throughout exhalation. This change in assessment indicates to the nurse that the client
Correct Answer: A
Rationale: Has increased airway obstruction. The higher pitched a sound is, the more narrow the airway.
Therefore, the obstruction has increased or worsened.
Question 2 of 5
The nurse is talking with an adult who says she has chronic constipation. What suggestion would probably be most helpful to the client?
Correct Answer: B
Rationale: Fruits and vegetables are high in fiber, promoting bowel regularity and alleviating constipation. Rice is low-fiber, Lomotil slows motility, and limiting fluids to meals can worsen constipation.
Question 3 of 5
An elderly client is returned to her room after an open reduction and internal fixation of the left femoral head after a fracture.
Correct Answer: D
Rationale: Coughing and deep breathing prevent respiratory complications like pneumonia, a significant risk due to immobility post-surgery. A high-residue diet prevents constipation, positioning varies, and exercises are secondary to respiratory care.
Question 4 of 5
A client who has a panic disorder is receiving paroxetine HCl (Paxil). The client has been taking the drug for one week and is still having severe panic attacks. The client tells the nurse that she thinks the drug is not working. What is the best response for the nurse to make?
Correct Answer: D
Rationale: Paroxetine, an SSRI, requires 2-4 weeks to reach therapeutic effect for panic disorder, explaining the continued symptoms.
Question 5 of 5
The nurse is caring for a client who is receiving IV vancomycin for a methicillin-resistant Staphylococcus aureus (MRSA) infection. Which of the following findings would be of GREATest concern to the nurse?
Correct Answer: C
Rationale: Redness at the IV site suggests phlebitis or infiltration, which can lead to tissue damage or reduced vancomycin delivery, requiring immediate action. Options A, B, and D are normal: blood pressure 130/80 mmHg, heart rate 88 bpm, and urine output 50 mL/hour indicate stability.