NCLEX-PN
NCLEX Trainer Test 2 Questions
Extract:
A client with a perforated bowel secondary to a bowel obstruction.
Question 1 of 5
At the time the diagnosis is made, which of the following should be a priority in the nursing care plan?
Correct Answer: C
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) client is kept in semi-Fowler's position (2) not a priority action (3) correct-when the bowel perforates as a result of increased intraluminal pressure within the gut, inTest inal contents are released into the peritoneum, leading to peritonitis (4) should not be done
Extract:
Question 2 of 5
The nurse is caring for a client who is 6 hours postoperative after an appendectomy. Which of the following findings would be of GREATest concern to the nurse?
Correct Answer: B
Rationale: A temperature of 100.8°F 6 hours post-appendectomy suggests infection, possibly from perforation or abscess, requiring immediate evaluation. Options A, C, and D are expected: heart rate 88 is normal, absent bowel sounds are typical post-surgery, and moderate pain is common.
Extract:
The nurse is caring for a client with organic brain syndrome in a long-term care facility.
Question 3 of 5
Which of the following actions by the nurse is BEST?
Correct Answer: D
Rationale: Strategy: The topic of the question is unstated. Read the answer choices for clues. (1) may not remember who or where he is (2) not as important as answer choice #4 (3) even with orientation, the client soon forgets (4) correct-geriatric client should be encouraged to talk about his life and important things in the past because he has recent memory loss
Extract:
Question 4 of 5
The nurse is performing an admission history for a client recovering from a stroke. Medication history reveals the drug clopidogrel (Plavix). Which clinical manifestation alerts the nurse to an adverse effect of this drug?
Correct Answer: A
Rationale: Clopidogrel is an antiplatelet medication that can increase the risk of bleeding, such as epistaxis (nosebleeds). Abdominal distention, nausea, and hyperactivity are not typical adverse effects of clopidogrel, so answers B, C, and D are incorrect.
Question 5 of 5
A 3 year-old child is brought to the clinic by his grandmother to be seen for 'scratching his bottom and wetting the bed at night.' Based on these complaints, the nurse would initially assess for which problem?
Correct Answer: D
Rationale: Pinworms are a common cause of anal itching and can contribute to bed-wetting in children due to discomfort. The nurse should assess for signs of pinworm infection, such as observing the anal area for worms or performing a tape test.