NCLEX-PN
NCLEX Trainer Test 3 Questions
Extract:
Question 1 of 5
After the anesthesiologist administers an epidural to a woman in labor, which of the following nursing actions has the HIGHEST priority?
Correct Answer: D
Rationale: Epidural anesthesia can cause hypotension, making blood pressure monitoring the priority to detect complications. Options A, B, and C are secondary or incorrect.
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.
Question 3 of 5
Which assessment finding is most indicative of increased ICP in a client admitted with a basilar skull fracture?
Correct Answer: D
Rationale: Papilledema, or swelling of the optic disc, is a specific sign of increased intracranial pressure due to pressure on the optic nerve. Nausea, vomiting, headache, and dizziness are less specific symptoms, so answers A, B, and C are incorrect.
Question 4 of 5
The nurse is caring for a client with a history of atrial fibrillation.
Correct Answer: C
Rationale: Warfarin is the standard anticoagulant for preventing thromboembolism in atrial fibrillation, reducing stroke risk. Aspirin and clopidogrel are antiplatelets, and heparin is used short-term or in acute settings.
Question 5 of 5
The physician has ordered insertion of a nasogastric tube to provide supplemental feedings for a client recovering from a stroke. To facilitate insertion of the nasogastric tube, the nurse should:
Correct Answer: B
Rationale: Flexing the neck aligns the esophagus, facilitating nasogastric tube insertion. Ice chips increase choking risk. Hyperextension misaligns the airway. Warm water is ineffective.