NCLEX-PN
NCLEX Trainer Test 2 Questions
Extract:
Question 1 of 5
After sustaining a closed head injury and numerous lacerations and abrasions to the face and neck, a five-year-old child is admitted to the emergency room.
Correct Answer: B
Rationale: Clear fluid draining from the ear suggests cerebrospinal fluid (CSF) leakage due to a meningeal rupture, a serious complication that risks meningitis and requires immediate reporting. Eyelid edema, minor bleeding, and withdrawal to pain are less urgent or expected findings.
Question 2 of 5
An involuntary psychiatric patient asks the nurse to mail his letter to the President. He states that the letter will make the President regret his actions to prevent homosexuals from serving in the military. Which of the following responses by the nurse is BEST?
Correct Answer: D
Rationale: Mailing the letter respects the patient’s communication rights while addressing potential concerns. Options A, B, and C violate autonomy or privacy.
Question 3 of 5
The nurse is caring for a client who is receiving a continuous IV infusion of insulin for diabetic ketoacidosis. Which of the following laboratory results should the nurse report immediately?
Correct Answer: B
Rationale: Hypokalemia (3.0 mEq/L) risks arrhythmias during insulin therapy for DKA. Options A, C, and D are less urgent.
Question 4 of 5
The nurse is assigned to a client who has heart failure. During the morning rounds the nurse sees the client develop sudden anxiety, diaphoresis and dyspnea. The nurse auscultates, crackles bilaterally. Which nursing intervention should be performed first?
Correct Answer: B
Rationale: Place the client in a sitting position with legs dangling. This reduces venous return, alleviating pulmonary edema symptoms.
Question 5 of 5
The nurse assesses an 18-month-old child brought to the well child clinic for a routine check-up. Which finding would be of most concern to the nurse?
Correct Answer: C
Rationale: Dropping objects handed to him suggests motor or neurological issues at 18 months, requiring evaluation. Creeping , not being toilet trained , and stranger anxiety are normal.