NCLEX-PN
NCLEX Trainer Test 1 Questions
Extract:
Question 1 of 5
An elderly client is admitted to a skilled nursing care facility. When doing a skin assessment, the nurse notes a 3-cm round area of partial-thickness skin loss that looks like a blister on the client's sacrum. The nurse interprets this to be a:
Correct Answer: B
Rationale: A stage II pressure ulcer involves partial-thickness skin loss, often presenting as a blister or shallow open ulcer, matching the description. Stage I is non-blanchable erythema, stage III involves full-thickness loss, and stage IV extends to muscle/bone.
Question 2 of 5
An adult who has multiple sclerosis is receiving cyclophosphamide (Cytoxan). The client asks the nurse why she is receiving the same drug her mother had when she had Hodgkin's disease. The nurse should include which information when responding?
Correct Answer: B
Rationale: Cyclophosphamide's immunosuppressive effect reduces immune activity in MS, where the immune system attacks nerves, unlike cancer treatment, symptom similarity, or shared etiology.
Question 3 of 5
The nurse is teaching a client with hypertension about lifestyle modifications. Which of the following recommendations is MOST appropriate?
Correct Answer: C
Rationale: Weight loss reduces blood pressure in hypertensive clients. Options A, B, and D worsen hypertension.
Extract:
A comatose patient who is incontinent.
Question 4 of 5
The nurse should intervene if which of the following actions is noted?
Correct Answer: A
Rationale: Strategy: 'Nurse should intervene' indicates that you are looking for an incorrect action. (1) correct-contaminated gloves should be removed before answering the phone (2) correct way to roll a patient to maintain proper alignment (3) appropriate to use incontinence pad for this patient (4) appropriate position to prevent aspiration and protect the airway
Extract:
Question 5 of 5
The nurse is caring for a neonate with an infection. The nurse would be MOST concerned if which of the following was observed?
Correct Answer: D
Rationale: A respiratory rate of 65 at rest (normal 30–50) indicates tachypnea, suggesting sepsis or hypoxia. Options A, B, and C are less concerning.