NCLEX-PN
NCLEX Trainer Test 2 Questions
Extract:
Question 1 of 5
At 10:00 A.M., the nurse discovers a 75-year-old woman who is hospitalized with congestive heart failure on the floor beside the bed. She has a bruise on her leg, but x-rays reveal no fractures. How should the nurse record the incident in the client's chart?
Correct Answer: B
Rationale: Accurate documentation includes specific details: time, client status, mechanism of fall, assessment findings (bruise size, orientation), and actions taken (physician notification, x-rays). This option is thorough and objective, unlike the others, which are vague or incomplete.
Question 2 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 3 of 5
The LPN/LVN is caring for an adult who has pneumonia. The nurse should instruct the nursing assistant to report which information immediately?
Correct Answer: A
Rationale: Restlessness may indicate hypoxia in pneumonia, a critical symptom requiring immediate reporting to assess oxygenation status.
Extract:
A client two days after surgery, a shiny, pink, open area is noted with the underlying bowel visible.
Question 4 of 5
When the nurse assesses the incision of a client two days after surgery, a shiny, pink, open area is noted with the underlying bowel visible. Which of these actions should the nurse take FIRST?
Correct Answer: A
Rationale: Strategy: All answers are implementation. Determine the outcome of each answer. Is it desired? (1) correct-evisceration is treated immediately by application of sterile gauze soaked in sterile normal saline, followed by notification of physician (2) not correct response to this complication (3) not correct response to this complication (4) not correct response to this complication
Extract:
Question 5 of 5
The nurse is doing a pain assessment on the client who has chronic back pain. Which assessment is of greatest value?
Correct Answer: C
Rationale: Self-reported pain rating (1-10 scale) is the most reliable indicator of pain intensity, guiding treatment effectively.