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
A 4 month-old child taking digoxin (Lanoxin) has a blood pressure of 92/78; resting pulse of 78 BPM; respirations 28 and a potassium level of 4.8 mEq/L. The client is irritable and has vomited twice since the morning dose of digoxin. Which finding is most indicative of digoxin toxicity?
Correct Answer: A
Rationale: Bradycardia. The most common sign of digoxin toxicity in children is bradycardia (heart rate below 100 BPM in an infant).
Question 3 of 5
The best nursing diagnosis for a client with newly diagnosed Diabetes Mellitus is:
Correct Answer: B
Rationale: Newly diagnosed diabetics need to learn about their disease, medications, glucose testing, possibly insulin injections, foot care, sick-day plans, and so forth.
Question 4 of 5
The nurse is caring for a client with a pressure ulcer.
Correct Answer: A
Rationale: A hydrocolloid dressing maintains a moist environment, promoting healing in a stage III pressure ulcer. Hydrogen peroxide is cytotoxic, repositioning every 2 hours is standard, and antibiotics are only used for infection.
Question 5 of 5
The nurse is caring for a client who had a cholecystectomy. Which of the following observations is MOST important for the nurse to report to the next shift?
Correct Answer: D
Rationale: Decreased breath sounds suggest atelectasis or pneumonia, serious post-cholecystectomy complications due to reduced ventilation from pain. Options A, B, and C are routine: resting is expected, absent bowel sounds are normal post-surgery, and IV rate is standard.