NCLEX-PN
NCLEX Trainer Test 3 Questions
Extract:
Question 1 of 5
A young child with a history of grand mal seizures is in public school. He is on phenobarbital and hydantoin (Dilantin) to control the seizures. His teacher tells the nurse that he has not had any seizures but he does keep falling asleep in class. What should the nurse include when discussing his drowsiness with the teacher?
Correct Answer: A
Rationale: Phenobarbital, a barbiturate, commonly causes drowsiness, explaining the child's sleepiness in class, which should be monitored but is expected.
Extract:
A ten-year-old child with leukemia has a large burn on her arm and the burn appears to be oily. The client states that she touched a hot pan, and her mother put cooking fat on it so it would not blister.
Question 2 of 5
The nurse should
Correct Answer: D
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) does not address the immediate problem of cleansing the wound (2) unnecessary (3) does not address the immediate problem of cleansing the wound (4) correct-because leukemic clients are immunosuppressed, they are more susceptible to infections; cooking fat applied to an open wound increases the possibility of infection; burns should be rinsed immediately with tap water to reduce the heat in the burn
Extract:
A client develops orthopnea, dyspnea, and basilar crackles.
Question 3 of 5
Which of the following nursing actions would be MOST appropriate for this client?
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) would worsen the situation (2) correct-orthopnea, dyspnea, and crackles are signs and symptoms of fluid excess; decreasing the IV fluids is the priority (3) not of priority in this situation (4) not of priority in this situation
Extract:
The nurse responds to a train derailment.
Question 4 of 5
After making an initial assessment, which of the following clients should the nurse see FIRST?
Correct Answer: B
Rationale: Strategy: Think ABCs. (1) requires further assessment, could be amniotic fluid or it could be urine (2) correct-indicates arterial bleeding; apply direct pressure; high risk for shock (3) stable patient (4) possible hip fracture, no indication of respiratory difficulty stated
Extract:
Question 5 of 5
An older adult is admitted with severe pneumonia. Which of the following measures should the nurse include in the plan of care immediately after admission? Select all that apply.
Correct Answer: A,B,C,D
Rationale: Fluids hydrate and thin secretions, antipyretics control fever, antibiotics treat infection, and mucolytics aid mucus clearance in pneumonia. Ambulation and large meals may be inappropriate initially due to fatigue.