NCLEX-PN
NCLEX Trainer Test 1 Questions
Extract:
A patient has a Sengstaken-Blakemore tube in place. The nurse enters the room and finds the woman in respiratory distress.
Question 1 of 5
It is MOST important for the nurse to
Correct Answer: C
Rationale: Strategy: Answers are all implementations. Determine the outcome of each answer choice. Is it desired? (1) need to remove tube immediately to provide for airway (2) does not provide a patent airway (3) correct-scissors always secured at the bedside, remove tube if observe signs of respiratory distress or airway obstruction caused by upward displacement of esophageal balloon (4) unnecessary to call code until respiratory arrest occurs, then establish a patent airway first
Extract:
Question 2 of 5
A client with pernicious anemia is admitted. What would the nurse expect the admitting assessment to reveal?
Correct Answer: B
Rationale: Pernicious anemia, a vitamin B12 deficiency, often causes neurological symptoms like bilateral leg neuropathy due to nerve demyelination.
Question 3 of 5
The nurse is providing home care to an elderly woman who had a cerebrovascular accident (CVA) and has right-sided hemiplegia. She is living with her daughter. Which observation indicates that the family needs more instruction?
Correct Answer: D
Rationale: Placing the chair on the right (paralyzed) side hinders safe transfers; it should be on the unaffected left side, indicating a need for further instruction.
Question 4 of 5
An elderly client is admitted to the unit with a temperature of $100.2^{\circ}$, urinary specific gravity of 1.032, and a dry tongue. The nurse should anticipate an order for:
Correct Answer: D
Rationale: The symptoms (fever, high urinary specific gravity, dry tongue) indicate dehydration. IV normal saline is the priority to rehydrate. Antibiotics require infection confirmation, analgesics address pain, and diuretics worsen dehydration.
Question 5 of 5
The nurse is supervising care given to a group of patients on the unit. The nurse observes a staff member entering a patient's room wearing gown and gloves. The nurse knows that the staff member is caring for which of the following patients?
Correct Answer: A
Rationale: acute viral infection; requires contact precautions; assign to private room or with other RSV-infected children