NCLEX-PN
NCLEX Trainer Test 6 Questions
Extract:
Question 1 of 5
An adult had major abdominal surgery this morning under general anesthesia. When the client arrives in the recovery room, she is very lethargic and restless. Her BP is 150/98; pulse is 110 and irregular; and respirations are 30 breaths per minute and shallow. Postoperative orders include meperidine (Demerol) 75 mg IM for operative site pain; reinforce dressings PRN; oxygen at 6 L/min PRN; irrigate nasogastric tube every 2 hours and PRN; IV 2500 cc D5W in 24 hours. What should the nurse do next?
Correct Answer: D
Rationale: Tachypnea, tachycardia, and restlessness suggest hypoxia. Administering oxygen at 6 L/min addresses this critical need. Dressings, nasogastric irrigation, and pain medication are secondary to stabilizing oxygenation.
Extract:
A student nurse obtaining an infant's vital signs.
Question 2 of 5
Which of the following actions should the student nurse complete FIRST?
Correct Answer: C
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) inappropriate to use probe to take axillary temperature (2) should count for a full minute (3) correct-respirations should be counted for one full minute prior to arousing the infant with a temperature probe or stethoscope (4) after infant is stimulated, crying may interfere with accurate evaluation of respirations
Extract:
Question 3 of 5
The nurse is assessing a client with complaints of right lower quadrant pain.
Correct Answer: A
Rationale: Inspection is the first step in abdominal assessment, allowing the nurse to observe for distention, masses, or visible abnormalities before proceeding to auscultation, percussion, and palpation. Palpation last prevents discomfort that could alter other findings.
Question 4 of 5
Digoxin has been prescribed for a 70-year-old man who has atrial fibrillation. Which behavior indicates that the client understands the nurse's instructions about taking digoxin?
Correct Answer: B
Rationale: Checking pulse before taking digoxin prevents administration if bradycardia is present, indicating understanding of toxicity monitoring.
Question 5 of 5
A mentally retarded, nonverbal, ambulatory client is found sitting on the floor unable to get up. The LPN/LVN notes the client appears to be in great pain, and his right leg is out of alignment. What is the most important action for the nurse to take as the client is readied for ambulance transport?
Correct Answer: B
Rationale: Immobilizing the leg prevents further injury in a suspected fracture, the priority action before transport.