NCLEX-PN
NCLEX Trainer Test 8 Questions
Extract:
Question 1 of 5
A young female teenager describes a brutal assault and rape to the nurse on duty. Which of the following actions should the nurse take first?
Correct Answer: B
Rationale: Emotional support is what that patient needs most at this point in time.
Question 2 of 5
The nurse notes dark red blood and a few clots in the catheter of a client two days after a transurethral prostatectomy (TURP). The nurse should first:
Correct Answer: B
Rationale: The appearance of dark red blood with a few clots indicates a venous bleed. Traction to the urethral catheter and increasing the client's fluid intake should be tried first before calling the doctor. Answer A would be indicated for the client with an arterial bleed, which is characterized by the appearance of bright red blood and many clots in the catheter, so it is incorrect.
Question 3 of 5
The nurse is caring for an adult who is taking digoxin (Lanoxin) 0.25 mg daily. Which comment by the client is of greatest concern to the nurse because the client is taking digoxin?
Correct Answer: C
Rationale: A pulse of 60 may indicate bradycardia, a potential sign of digoxin toxicity, requiring immediate assessment. Anorexia and fatigue are less specific, and foot pain is unrelated to digoxin.
Question 4 of 5
A 5-year-old child has been treated for sickle cell crisis. The parent asks the nurse if there is anything that can be done to prevent future crises. What should be included in the nurse's response?
Correct Answer: C
Rationale: Fevers, vomiting, and diarrhea can trigger sickle cell crisis by causing dehydration or infection, so prompt reporting allows early intervention to prevent crises.
Extract:
A client with a neurological disorder.
Question 5 of 5
Which of the following nursing assessments will be MOST helpful in determining subtle changes in the client's level of consciousness?
Correct Answer: B
Rationale: Strategy: Think about each answer choice. (1) indicates increased intracranial pressure (2) correct-Glasgow coma scale score best evaluates changes in a client's level of consciousness by evaluating eye-opening, motor, and verbal responses (3) more appropriate for the psychiatric client (4) more appropriate for the psychiatric client