NCLEX-PN
NCLEX Trainer Test 9 Questions
Extract:
Question 1 of 5
A client with chronic congestive heart failure should be instructed to contact the home health nurse if which finding occurs?
Correct Answer: A
Rationale: Weight gain of 2 pounds or more in a 48 hour period. It is critical for clients to report and be treated for rapid weight gain, which indicates fluid retention and worsening heart failure.
Question 2 of 5
The nurse is caring for a client with a suspected pulmonary embolism.
Correct Answer: B
Rationale: A D-dimer blood Test is a sensitive screening tool for pulmonary embolism, detecting fibrin degradation products from a clot. Chest X-ray and ECG are non-specific, and ABG assesses oxygenation but not the diagnosis directly.
Question 3 of 5
A four-year-old is admitted with drooling and an inflamed epiglottis. During the assessment, the nurse would identify which of the following symptoms as indicative of an increase in respiratory distress?
Correct Answer: B
Rationale: increase in the respiratory rate is an early sign of hypoxia, also for tachycardia
Question 4 of 5
The nurse is caring for a client with Rheumatoid Arthritis. Which nursing diagnosis should receive priority in the plan of care?
Correct Answer: C
Rationale: Alteration in comfort. Relieving pain is the number one objective of this client's plan of care.
Extract:
A 67-year-old man following a cardiac catheterization. Two hours after the procedure, the nurse checks the patient's insertion site in the antecubital space, and the patient complains that his hand is numb.
Question 5 of 5
The nurse should
Correct Answer: C
Rationale: Strategy: Answers are a mix of assessments and implementations. Does the assessment answer validate what is going on? No. Determine the outcome of each answer choice. (1) assumes that numbness is related to positioning of hand, not circulatory changes (2) part of assessment, but doesn't indicate status of circulation (3) correct-absent or weak pulse or numbness could indicate problem with circulation, anticoagulants and vasodilators may be ordered (4) assumes that numbness is related to immobility of fingers, not circulatory changes