NCLEX-PN
NCLEX Trainer Test 2 Questions
Extract:
Question 1 of 5
An elderly client is returned to her room after an open reduction and internal fixation of the left femoral head after a fracture.
Correct Answer: D
Rationale: Coughing and deep breathing prevent respiratory complications like pneumonia, a significant risk due to immobility post-surgery. A high-residue diet prevents constipation, positioning varies, and exercises are secondary to respiratory care.
Question 2 of 5
The nurse is screening an eight-month-old girl in a well-baby clinic. The nurse would be MOST concerned if the infant's mother made which of the following statements?
Correct Answer: A
Rationale: An eight-month-old should have doubled birth weight by 5–6 months; 'almost doubled' suggests growth delay, requiring evaluation. Options B, C, and D are normal behaviors.
Question 3 of 5
The nurse is caring for a client with a history of myocardial infarction.
Correct Answer: A
Rationale: Avoiding heavy lifting for 6 weeks prevents cardiac strain during myocardial healing. Nitroglycerin is used for angina, gradual activity resumption is advised, and blood pressure monitoring is routine but secondary.
Question 4 of 5
The nurse is assessing a client who has had a spinal cord injury. Which of the following assessment findings would suggest the complication of autonomic dysreflexia?
Correct Answer: B
Rationale: severe headache results from rapid onset of hypertension
Question 5 of 5
The nurse is caring for a client who is receiving IV vancomycin for a methicillin-resistant Staphylococcus aureus (MRSA) infection. Which of the following findings would be of GREATest concern to the nurse?
Correct Answer: C
Rationale: Redness at the IV site suggests phlebitis or infiltration, which can lead to tissue damage or reduced vancomycin delivery, requiring immediate action. Options A, B, and D are normal: blood pressure 130/80 mmHg, heart rate 88 bpm, and urine output 50 mL/hour indicate stability.