NCLEX-PN
NCLEX Trainer Test 8 Questions
Extract:
A client with signs of increased intracranial pressure (ICP).
Question 1 of 5
In planning care for a client with signs of increased intracranial pressure (ICP), the nurse would include which of the following?
Correct Answer: D
Rationale: Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. (1) increases intracranial pressure (2) increases intracranial pressure (3) head of the bed should be elevated 15 to 30° to promote venous drainage (4) correct-assessment, cough or gag reflex and the swallowing reflex may be affected by the increased pressure; increases the incidence of aspiration
Extract:
Question 2 of 5
The nurse notes dark red blood and a few clots in the catheter of a client two days after a transurethral prostatectomy (TURP). The nurse should first:
Correct Answer: B
Rationale: The appearance of dark red blood with a few clots indicates a venous bleed. Traction to the urethral catheter and increasing the client's fluid intake should be tried first before calling the doctor. Answer A would be indicated for the client with an arterial bleed, which is characterized by the appearance of bright red blood and many clots in the catheter, so it is incorrect.
Question 3 of 5
Which type of traction can the nurse expect to be used on a 7 year-old with a fractured femur and extensive skin damage?
Correct Answer: A
Rationale: Ninety degree-ninety degree traction is used for fractures of the femur or tibia. A skeletal pin or wire is surgically placed through the distal part of the femur, while the lower part of the extremity is in a boot cast. Traction ropes and pulleys are applied.
Question 4 of 5
The nurse is teaching home care to the parents of a child with acute spasmodic croup. The most important aspects of this care is/are
Correct Answer: C
Rationale: humidified air and increased oral fluids. The most important aspects of home care for a child with acute spasmodic croup are humidified air and increased oral fluids. Moisture soothes inflamed membranes. Adequate systemic hydration aids in mucociliary clearance and keeps secretions thin, white, watery, and easily removed with minimal coughing.
Extract:
A 32-year-old multipara is seen in the prenatal clinic. The nurse notes she is in her fifth month of pregnancy and has a weight gain of 14 pounds. The history indicates that prenatally the client was of average height and weight.
Question 5 of 5
The nurse should advise the client that
Correct Answer: C
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) excessive weight gain is >6.6 lb (3 kg)/month (2) inadequate weight gain is <2.2 lb (1 kg)/month (3) correct-weight gain 2-5 lb (2.5 kg) first trimester, 0.66-1.1 lb (0.5 kg) weekly in second and third trimester (4) not substantiated by information presented in question