NCLEX-PN
NCLEX Trainer Test 6 Questions
Extract:
A client had a radical mastectomy for cancer in her right breast.
Question 1 of 5
After the client returns to the unit, which of the following actions, if performed by the nurse, would be MOST appropriate?
Correct Answer: C
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) sling is not necessary, arm needs to be elevated (2) right arm cannot be elevated from this position (3) correct-this position will facilitate removal of fluid from venous pathways and lymphatic system through gravity; arm is elevated to enhance circulation and prevent edema (4) prone position is not appropriate
Extract:
Question 2 of 5
Which of the following assessment findings would indicate to the nurse the need for more sedation in a client who is withdrawing from alcohol dependence?
Correct Answer: A
Rationale: Steadily increasing vital signs (e.g., heart rate, blood pressure) indicate progression toward delirium tremens, a life-threatening complication of alcohol withdrawal, necessitating additional sedation. Mild tremors, decreased respirations, or gastroinTest inal symptoms are expected or contraindicate more sedation.
Question 3 of 5
A 78-year-old client is admitted in heart failure. Which assessment is essential for the nurse to make because the client is in heart failure? Select all that apply.
Correct Answer: B,D,E
Rationale: Persons who are in heart failure are at risk for developing pulmonary edema. The nurse should listen for lung sounds, check legs for pitting edema, which is common in heart failure, and observe respirations for severe dyspnea. Pedal pulses, upper extremity neuro checks, and gait disturbances are not related to heart failure or to pulmonary edema.
Question 4 of 5
A client has developed a low inTest inal obstruction. The nurse would anticipate which of the following findings?
Correct Answer: A
Rationale: there is distention above the level of obstruction and initially hyperactive bowel sounds; would be no stool, as motility distal to (below) the obstruction would cease
Question 5 of 5
The nurse is teaching the client with an ileal conduit regarding skin care to prevent excoriation. In addition to applying a well-fitted collection bag the client should be told to empty the collection bag:
Correct Answer: D
Rationale: The client should be told to empty the collection bag when it is one-third full. Answer A isn't necessary or feasible, so it is incorrect. Waiting until the collection bag is half full or more as suggested in answers B and C increases the likelihood of skin exposure to urine thereby contributing to excoriation.