NCLEX-PN
NCLEX Trainer Test 3 Questions
Extract:
An 85-year-old woman recovering from a fractured pelvis in a long-term care facility. The woman's activity order reads: ambulate with walker bid.
Question 1 of 5
After the nurse implements the order, which of the following charting entries is BEST?
Correct Answer: D
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) gives subjective information (2) gives judgments without objective information (3) information is not complete, contains some judgments without objective information (4) correct-gives objective information
Extract:
Question 2 of 5
The registered nurse has just admitted a client with severe depression. What domain should be the priority focus as the nurse identifies the nursing diagnoses?
Correct Answer: D
Rationale: Safety. A depressed client is at acute risk for self-destructive behavior, making safety the priority.
Extract:
A client has a nasogastric tube in place after extensive abdominal surgery. The client complains of nausea. His abdomen is distended, and there are no bowel sounds.
Question 3 of 5
The FIRST nursing action should be to
Correct Answer: C
Rationale: Strategy: Answers are a mix of assessments and implementations. Is this a situation that requires assessment? Yes. (1) implementation, may be carried out after the patency of the tube is determined (2) implementation, patency should be checked first (3) correct-should first assess if the tube is open and draining to determine if there is a problem with the nasogastric tube; if it is patent and draining it does not need to be irrigated (4) assessment, patency should be checked first by aspirating stomach contents, not by auscultation
Extract:
Question 4 of 5
An adolescent is to be admitted to the orthopedic floor with several fractures. The client has been taking hallucinogens this evening. What should the nurse expect on admission because the client is using hallucinogens?
Correct Answer: B
Rationale: Hallucinogens can cause agitation or violent behavior due to altered perceptions, especially in a stressful hospital setting. Depression, respiratory distress, or convulsions are less common.
Extract:
The nurse is performing teaching for a client being discharged on clozapine (Clozaril).
Question 5 of 5
Which of the following client statements indicates to the nurse that teaching has been successful?
Correct Answer: B
Rationale: Strategy: 'Teaching has been successful' indicates a correct response. (1) follow routine schedule (2) correct-Clozaril causes agranulocytosis; requires weekly WBC; teach client to report early signs of infection (3) check with physician before taking any OTC medication (4) check with physician before ingesting alcohol