NCLEX-PN
NCLEX Trainer Test 3 Questions
Extract:
A client describing seeing snakes on the walls of his room in a psychiatric facility.
Question 1 of 5
Based on this information, the nurse should identify a nursing diagnosis of
Correct Answer: A
Rationale: Strategy: Think about each answer choice. (1) correct-reflects a pattern of impaired perception, which is supported by the data that client is having a hallucination, defined as a sensory perception for which no external stimuli exist (2) not relevant to the data (3) not relevant to the data (4) not relevant to the data
Extract:
Question 2 of 5
After admission for elective surgery, an adult says to the nurse, 'They asked me if I had advance directives. I don't even know what that is.' What is the best response by the nurse?
Correct Answer: B
Rationale: Advance directives specify healthcare preferences for incapacitation, relevant for any adult, clearly explaining their purpose.
Question 3 of 5
The nurse is caring for a client with possible cervical cancer. What clinical data would the nurse most expect to find in the client's history?
Correct Answer: A
Rationale: Postcoital vaginal bleeding is a hallmark symptom of cervical cancer due to tumor involvement of the cervix. Nausea, vomiting, foul-smelling discharge, and hyperthermia may occur in advanced stages or infections but are less specific, so B, C, and D are incorrect.
Question 4 of 5
The nurse is to administer the daily dose of digoxin to an adult client. What is it essential for the nurse to do before administering the medication?
Correct Answer: D
Rationale: Digoxin slows heart rate; checking the apical pulse ensures it's above 60 bpm to avoid bradycardia. Temperature, blood pressure, and respirations are less critical.
Question 5 of 5
The nurse in a long-term care facility wants to help a resident become continent of stools. Which is likely to be most helpful when planning care for the resident? Select all that apply.
Correct Answer: A,C,D
Rationale:
Toileting after meals leverages the gastrocolic reflex, fluids soften stool, and walking stimulates peristalsis, all promoting continence. Limiting fiber, listing foods, or discouraging snacking are less effective or counterproductive.