NCLEX-PN
NCLEX Trainer Test 8 Questions
Extract:
A young adult immobilized for trauma to the spinal cord has periods of diaphoresis, a draining abdominal wound, and diarrhea.
Question 1 of 5
Based on the nursing assessment, an appropriate priority nursing diagnosis is
Correct Answer: B
Rationale: Strategy: Think about each answer choice. (1) constipation is not a problem because the client has diarrhea (2) correct-skin is very susceptible to breakdown because of immobility and bodily secretions; needs numerous nursing interventions to prevent this (3) not most important (4) there would be risk of fluid volume deficit due to diarrhea and secretions
Extract:
A 62-year-old man who is scheduled for a total laryngectomy.
Question 2 of 5
Which of the following statements, if made by the family, would indicate to the nurse a need for further teaching?
Correct Answer: C
Rationale: Strategy: 'Further teaching is necessary' indicates an incorrect response. (1) will communicate in writing initially, then artificial larynx or esophageal speech (2) will require laryngectomy tube to prevent scar tissue contracture (3) correct-requires nutritional support for 10 days until wound heals, then gradually resumes oral intake (4) common with total laryngectomy
Extract:
Question 3 of 5
The nurse is caring for a client with a sigmoid colostomy who requests assistance in removing the flatus from a 1 piece drainable ostomy pouch. Which is the correct intervention?
Correct Answer: B
Rationale: Opening the bottom of the pouch, allowing the flatus to be expelled, is the correct way to vent a 1-piece drainable ostomy pouch.
Question 4 of 5
A woman is seen in clinic with complaints suggesting cholecystitis or cholelithiasis. What teaching should the nurse expect to reinforce?
Correct Answer: D
Rationale: Fatty foods trigger gallbladder contraction, worsening pain in cholecystitis or cholelithiasis; avoiding them reduces symptoms. Sitting up, carbonated drinks, or caffeine are less critical.
Question 5 of 5
The nurse is caring for a client who is receiving chemotherapy and has a platelet count of 50,000/mm^3. Which of the following actions is the PRIORITY?
Correct Answer: B
Rationale: A platelet count of 50,000/mm^3 indicates thrombocytopenia, increasing bleeding risk. Monitoring for bleeding (e.g., petechiae, hematomas) is the priority to detect complications early. Options A, C, and D are secondary: pain management, ambulation, and diet are less urgent.