NCLEX-PN
NCLEX Trainer Test 3 Questions
Extract:
Question 1 of 5
An 80 year-old nursing home resident has a temperature of 101.6 degrees Fahrenheit rectally. This is a sudden change in an otherwise healthy client. Which should the nurse assess first?
Correct Answer: C
Rationale: Level of alertness. Assessing the level of consciousness (alert vs. lethargic vs. unresponsive) will help the provider determine the severity of the acute episode. If the client is alert, responses to questions about complaints can be followed-up quickly.
Question 2 of 5
The nurse is aware that the effect of antihypertensive drug therapy may be affected by a 75 year-old client's
Correct Answer: B
Rationale: Decreased gastrointestinal motility, together with shrinkage of the gastric mucosa and changes in hydrochloric acid levels, will decrease absorption of medications and interfere with their actions.
Question 3 of 5
A young child with a history of grand mal seizures is in public school. He is on phenobarbital and hydantoin (Dilantin) to control the seizures. His teacher tells the nurse that he has not had any seizures but he does keep falling asleep in class. What should the nurse include when discussing his drowsiness with the teacher?
Correct Answer: A
Rationale: Phenobarbital, a barbiturate, commonly causes drowsiness, explaining the child's sleepiness in class, which should be monitored but is expected.
Question 4 of 5
The nurse is caring for an 11-year-old patient being treated for a fractured right femur with balanced suspension traction with a Thomas splint and Pearson attachment.
Correct Answer: A
Rationale: A trochanter roll placed on the outer aspect of the thigh prevents external rotation by holding the hip in a neutral position and maintaining normal leg alignment. Resistive exercises, manual repositioning, or instructing the patient to maintain position are less effective, as they do not provide sustained support to prevent rotation.
Question 5 of 5
The nurse is performing a physical assessment on a client with insulin dependent diabetes mellitus. Which client finding calls for immediate nursing action?
Correct Answer: A
Rationale: Diaphoresis and shakiness. Diaphoresis is a sign of hypoglycemia, which warrants immediate attention to prevent severe complications.