NCLEX-PN
NCLEX Trainer Test 7 Questions
Extract:
Question 1 of 5
After a client develops left-sided hemiparesis from a cerebral vascular accident (CVA), there is a decrease in muscle tone.
Correct Answer: B
Rationale: Decreased tissue oxygenation from impaired circulation in hemiparesis is the leading cause of skin breakdown, making this the priority nursing diagnosis. Mobility and immobility are concerns, but tissue perfusion is more critical, and communication issues are more relevant to right-sided CVA.
Question 2 of 5
The nurse is caring for a client with a fractured femur in traction.
Correct Answer: C
Rationale: Numbness in the affected leg suggests possible neurovascular compromise, requiring immediate assessment of circulation, sensation, and motor function. Adjusting traction, checking pin sites, or giving pain medication does not address the urgent need to evaluate neurovascular status.
Question 3 of 5
The nurse is caring for a client who has dentures. Which action by the nurse is not appropriate?
Correct Answer: C
Rationale: Hydrogen peroxide can damage dentures; rinsing with water or denture cleaner is appropriate, making this action incorrect.
Question 4 of 5
The nurse is caring for a client with a history of asthma who is receiving albuterol via nebulizer. Which of the following findings should the nurse report immediately?
Correct Answer: A
Rationale: A heart rate of 120 bpm suggests tachycardia, a serious albuterol side effect. Options B, C, and D are normal or expected.
Question 5 of 5
The nurse is caring for a post-operative client who develops a wound evisceration. The first nursing intervention should be
Correct Answer: C
Rationale: When evisceration occurs, the wound should first be quickly covered by sterile dressings soaked in sterile saline. This prevents tissue damage until a repair can be effected.