NCLEX-PN
NCLEX Trainer Test 3 Questions
Extract:
Question 1 of 5
An elderly client with a fractured hip is placed in Buck's traction. The primary purpose for Buck's traction for this client is:
Correct Answer: A
Rationale: Buck's traction immobilizes the hip to reduce muscle spasms, which can worsen pain and misalignment. It does not prevent surgery or bleeding and is not primarily for pain relief.
Question 2 of 5
A client has a repair of a hiatal hernia using a thoracic approach. During the immediate post-op period, the nurse should carefully assess the client for:
Correct Answer: B
Rationale: A thoracic approach affects the chest, so respiratory changes (e.g., distress, decreased oxygen saturation) are critical to assess post-op. Appetite, anxiety, and activity intolerance are less immediate concerns.
Question 3 of 5
The nursing team includes two RNs, one LPN/LVN, and one nursing assistant.
Correct Answer: A
Rationale: Nursing assistants can care for clients with standard, unchanging procedures like feeding an Alzheimer’s patient. Clients with urinary symptoms, tube feedings, or unstable respirations require RN or LPN assessment and intervention.
Question 4 of 5
The nurse should visit which of the following clients first?
Correct Answer: C
Rationale: Chest pain in a client with a history of angina suggests possible acute coronary syndrome, requiring immediate assessment to rule out myocardial infarction.
Extract:
A client is scheduled for a cardiac catheterization at 8 AM. The client's laboratory work was completed five days ago. The results were: K⺠3.0 mEq/L, Na⺠148 mEq/L, glucose 178 mg/dL. He complains of muscle weakness and cramps.
Question 5 of 5
Which of the following nursing actions is BEST?
Correct Answer: C
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) Aldactone is potassium-sparing diuretic and is an oral medication, patient is NPO for procedure (2) is not feasible prior to the cardiac cath because the client is NPO (3) correct-signs and symptoms are indicative of hypokalemia; stat serum K⺠level is needed to confirm the K⺠level prior to going for cardiac catheterization (4) is unnecessary at this time