NCLEX-PN
NCLEX Trainer Test 5 Questions
Extract:
Question 1 of 5
A nurse is assessing a patient in the rehab unit at shift change. The patient has suffered a TBI 3 weeks ago. Which of the following is the most distinguishing characteristic of a neurological disturbance?
Correct Answer: A
Rationale: LOC is the most critical indicator of impaired neurological capabilities.
Question 2 of 5
The nurse is caring for a client on complete bed rest. Which action by the nurse is most important in preventing the formation of deep vein thrombosis?
Correct Answer: D
Rationale: Preventing popliteal pressure will prevent venous stasis and possibly deep vein thrombosis.
Question 3 of 5
The best diet for the client with Meniere's disease is one that is:
Correct Answer: B
Rationale: A low-sodium diet reduces fluid retention in Meniere's disease, alleviating vertigo. Fiber (A,
D) and iodine are unrelated to symptom management.
Question 4 of 5
The nurse is caring for a client following removal of the thyroid. Immediately post-op the nurse should:
Correct Answer: A
Rationale: Semi-Fowler's position reduces swelling and supports the surgical site post-thyroidectomy. Turning the head or flexing the neck risks wound dehiscence. Supine with sandbags is unnecessary and uncomfortable.
Extract:
A client has returned to the floor from thyroidectomy surgery.
Question 5 of 5
After a client has returned to the floor from thyroidectomy surgery, it is MOST important for the nurse to take which of the following actions?
Correct Answer: C
Rationale: Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. Determine what assessment is being made in each answer choice. (1) assessment is not specific to this surgery (2) assessment, method used to monitor for postoperative hemorrhage in a tonsillectomy client (3) correct-assessment, after surgery, swelling can occur, which causes respiratory distress (4) implementation, head of the bed should be elevated