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
When an autistic client begins to eat with her hands, the nurse can best handle the problem by
Correct Answer: A
Rationale: Placing the spoon in the client's hand and stating, 'Use the spoon to eat your food.' This provides clear instruction and encourages adaptive behavior.
Question 3 of 5
The parents of a one-month-old boy bring their son to the clinic for evaluation of a possible right dislocated hip.
Correct Answer: B
Rationale: Unilateral hip dislocation causes uneven gluteal folds and thigh creases, with deeper and longer folds on the affected side due to hip displacement. Limited abduction (not adduction), shortened limb length, and variable rotation are more typical findings.
Question 4 of 5
A newborn has hyperbilirubinemia and is undergoing phototherapy with a fiberoptic blanket. Which safety measure is most important during this process?
Correct Answer: C
Rationale: Provide water feedings at least every 2 hours. Protecting the eyes of the neonates is very important to prevent damage when under the ultraviolet lights, but since the blanket is used, extra protection of the eyes is unnecessary. It is recommended that the neonate remain under the lights for extended periods. The neonate's skin is exposed to the light and the temperature is monitored, but a heater may not be necessary. There is no reason to withhold feedings. Frequent water or feedings are given to help with the excretion of the bilirubin in the stool.
Extract:
A client experiencing hallucinations.
Question 5 of 5
Which of the following behaviors by a client should the nurse record to indicate that the client is experiencing hallucinations?
Correct Answer: B
Rationale: Strategy: Think about each answer choice. (1) describes behavior associated with depression (2) correct-hallucinations are sensory perceptions for which there is no external stimulus; this option describes client behavior that would be observed when the client is responding to voices (3) describes behavior associated with delusional thinking (4) describes behavior most associated with anxiety