NCLEX-PN
NCLEX Trainer Test 3 Questions
Extract:
The nurse responds to a train derailment.
Question 1 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 2 of 5
The nurse is caring for a 78-year-old woman in a long-term care facility. The client is sitting in a geriatric chair with the attached tray in place. The client is agitated and appears to be sliding down in the chair. What is the best action for the nurse to take?
Correct Answer: D
Rationale: Foam wedges stabilize the client safely and comfortably, preventing sliding without restrictive measures. Restraints (jacket or sheet) increase agitation and risk, and consulting the supervisor delays action.
Extract:
A 56-year-old woman hospitalized with bipolar disorder. While the patient is in the manic phase.
Question 3 of 5
Nursing interventions should involve
Correct Answer: B
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) will not be effective in changing behaviors, requires an attentive listener (2) correct-patient experiences hyperactivity, poor concentration, and distractibility, redirect into activity that promotes rest, nourishment, reduce stimuli (3) isolation not required, would increase anxiety and hostility (4) disorientation usually not seen, no memory disturbance
Extract:
Question 4 of 5
The nurse is to make several home visits today. All of the visits are within a 5-mile radius. All of the following persons need to be seen. Which person should the nurse visit first?
Correct Answer: A
Rationale: Leg ulcers in a diabetic with peripheral vascular disease pose infection and healing risks, prioritizing wound care. Other needs are less urgent.
Question 5 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.