NCLEX-PN
NCLEX-PN Free Practice Questions Questions
Extract:
Question 1 of 5
A toddler is diagnosed with a dislocated right shoulder and a simple fracture of the right humerus. Which behavior most strongly suggests that the child's injuries stem from abuse?
Correct Answer: D
Rationale: Not crying when moved most strongly suggests child abuse. A victim of child abuse typically doesn't complain of pain, even with obvious injuries, for fear of further displeasing the abuser. Trying to sit up on the stretcher is a typical client response. Trying to move away from the nurse indicates fear of strangers, which is normal in a toddler. Difficulty answering the nurse's questions is expected in a toddler because of poorly developed cognitive skills.
Extract:
An assessment of a 6-month-old infant's growth and development level should reveal that the infant can:
Question 2 of 5
An assessment of a 6-month-old infant's growth and development level should reveal that the infant can:
Correct Answer: D
Rationale: At 6 months, infants can hold a bottle, a developmental milestone.
Extract:
Question 3 of 5
The nurse is caring for a post-op colostomy client. The client begins to cry, saying 'I'll never be attractive again with this ugly red thing.' What should be the first action taken by the nurse?
Correct Answer: D
Rationale: Encourage the client to discuss her feelings about the colostomy. Assessing the client's personal feelings about the stoma and colostomy care is essential to identify specific concerns before offering solutions.
Extract:
The physician orders a paracentesis for a patient with ascites.
Question 4 of 5
Before the procedure, the nurse should instruct the patient to:
Correct Answer: A
Rationale: Emptying the bladder prevents injury during paracentesis needle insertion.
Extract:
Question 5 of 5
The nurse is preparing to boost a client up in bed. She instructs the client to use the overbed trapeze. Which risk factor for pressure ulcer development is the nurse reducing by instructing the client to move in this manner?
Correct Answer: D
Rationale: Using a trapeze reduces shearing forces (opposing forces that cause layers of skin to move over each other, stretching and tearing capillaries and, eventually, resulting in necrosis), which increase the risk of pressure ulcer development. They can occur as clients slide down in bed or when they're pulled up in bed.
To reduce shearing forces, the nurse should instruct the client to use an overbed trapeze, place a draw sheet under the client to move the client up in bed, and keep the head of the bed no higher than 30 degrees. The risks of friction, impaired circulation, and localized pressure aren't decreased with trapeze use.