NCLEX-PN
NCLEX Trainer Test 7 Questions
Extract:
Question 1 of 5
A four-month-old child is admitted with a tentative diagnosis of meningitis.
Correct Answer: A
Rationale: Restraining the child during a lumbar puncture prevents movement, reducing the risk of spinal trauma. Parental instruction and emotional support are important but secondary, and elevating the head is inappropriate for positioning.
Question 2 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 would be of GREATest concern to the nurse?
Correct Answer: C
Rationale: Chest tube drainage of 150 mL/hour is excessive post-CABG, suggesting hemorrhage, requiring immediate evaluation. Options A, B, and D are less concerning: heart rate 100 bpm and temperature 100.8°F are common, and blood pressure 130/80 mmHg is normal.
Question 3 of 5
On the third post-burn day, the nurse finds that the client's hourly urine output is 26 ml. The nurse should continue to assess the client and notify the doctor for an order to:
Correct Answer: D
Rationale: The urinary output should be maintained between 30 ml and 50 ml per hour. The first action should be to increase the IV rate to prevent increased acidosis. Answer A would lead to diminished output, so it is incorrect. There is no indication that the type of IV fluid is not appropriate as is suggested by answer B, making it incorrect. Answer C would not increase the client's output and would place the client at greater risk for infection, so it is incorrect.
Extract:
A client is scheduled for a myelogram at the outpatient clinic.
Question 4 of 5
Which of the following statements, if made by the nurse, correctly describes a myelogram?
Correct Answer: C
Rationale: Strategy: Determine how each answer choice relates to a myelogram. (1) x-ray examination cannot determine the extent of myelin breakdown (2) no such procedure (3) correct-contrast medium or air is injected into spinal subarachnoid space through a spinal puncture, identifies tumors, cysts, herniated vertebral discs (4) no such procedure
Extract:
Question 5 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.