NCLEX-PN
NCLEX Trainer Test 3 Questions
Extract:
Question 1 of 5
A wet-to-dry dressing is ordered for a client who has a decubitus ulcer. Which technique is appropriate?
Correct Answer: C
Rationale: Wet-to-dry dressings involve a moist gauze applied to the wound, covered with dry gauze, to debride tissue as it dries. Other techniques are incorrect.
Question 2 of 5
The nurse is performing a physical assessment on a client with insulin dependent diabetes mellitus. Which client finding calls for immediate nursing action?
Correct Answer: A
Rationale: Diaphoresis and shakiness. Diaphoresis is a sign of hypoglycemia, which warrants immediate attention to prevent severe complications.
Extract:
A 19-year-old woman after delivery of a 7 lb 10 oz baby boy. The patient has decided to bottle-feed her infant.
Question 3 of 5
The nurse should encourage the patient to
Correct Answer: D
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) will encourage milk secretion (2) will enhance flow of milk (3) may be taut due to engorgement, massage would be painful and unnecessary, will encourage milk flow (4) correct-will help minimize discomfort during period of engorgement
Extract:
Question 4 of 5
The client is scheduled for a myelogram today. The permit has been signed. The client tells the nurse that she has changed her mind and does not want to have the procedure. What should the nurse do?
Correct Answer: D
Rationale: Clients have the right to withdraw consent at any time, respecting autonomy. Coercion or suggesting physician displeasure is unethical.
Extract:
A client has a nasogastric tube in place after extensive abdominal surgery. The client complains of nausea. His abdomen is distended, and there are no bowel sounds.
Question 5 of 5
The FIRST nursing action should be to
Correct Answer: C
Rationale: Strategy: Answers are a mix of assessments and implementations. Is this a situation that requires assessment? Yes. (1) implementation, may be carried out after the patency of the tube is determined (2) implementation, patency should be checked first (3) correct-should first assess if the tube is open and draining to determine if there is a problem with the nasogastric tube; if it is patent and draining it does not need to be irrigated (4) assessment, patency should be checked first by aspirating stomach contents, not by auscultation