NCLEX-PN
NCLEX Trainer Test 5 Questions
Extract:
A multipara client who delivered a female infant one hour ago. The nurse observes that the client's breasts are soft; the uterus is boggy, to the right of the midline, and 2 cm below the umbilicus; moderate lochia rubra.
Question 1 of 5
It is MOST important for the nurse to take which of the following actions?
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) encourage the client to void before catheterizing (2) correct-boggy uterus deviated to right indicates full bladder, encourage client to void (3) will increase uterine tone, but the problem is a full bladder (4) findings indicate a full bladder
Extract:
Question 2 of 5
A client is discharged following hospitalization for congestive heart failure. The nurse teaching the family suggests they encourage the client to rest frequently in which of the following positions?
Correct Answer: A
Rationale: High Fowler's. This position decreases cardiac workload and facilitates breathing.
Extract:
An adolescent for a lumbar puncture.
Question 3 of 5
It is MOST important that the nurse make which of the following statements?
Correct Answer: C
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) general anesthetic is not used (2) fluids are not restricted before the Test (3) correct-to prevent a post-lumbar puncture headache, client should remain flat in bed for eight hours after the Test (4) inappropriate for this procedure
Extract:
A client with a marked depression of T cells.
Question 4 of 5
To promote safety in the environment of a client with a marked depression of T cells, the nurse should
Correct Answer: D
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) protocol for handling soiled articles is accomplished within universal guidelines with double biohazard bags (2) universal precautions and client protection may call for plastic utensils, but not just spoons (3) not protocol unless the client has an active pulmonary infection (4) correct-water should not be allowed to stand in containers, such as respiratory or suction equipment, because this could act as a culture medium
Extract:
Question 5 of 5
The nurse is teaching a client with a new diagnosis of atrial fibrillation about diltiazem (Cardizem). Which of the following statements by the client indicates a need for further teaching?
Correct Answer: C
Rationale: Taking diltiazem with grapefruit juice is incorrect, as it increases drug levels, risking toxicity. Options A, B, and D are correct: pulse monitoring detects bradycardia, leg swelling may indicate heart failure, and avoiding driving with dizziness prevents accidents.