NCLEX-PN
NCLEX Trainer Test 10 Questions
Extract:
Question 1 of 5
On a home health visit, an elderly client states, 'This neighborhood has really gone down. I feel like a prisoner in my own home with all the trouble out there.' Which of the following nursing responses by the nurse is BEST?
Correct Answer: D
Rationale: assessing the basis for client's fears and encouraging client to talk about them is the first positive step
Question 2 of 5
The nurse is performing an ice massage for a client in chronic pain. The nurse is MOST concerned if which of the following is observed?
Correct Answer: B
Rationale: Mottling or graying indicates potential frostbite or tissue damage, a serious concern requiring immediate cessation of ice massage. Options A, C, and D are less critical: redness is common, burning/tingling suggests ischemia, and numbness/cold is expected.
Question 3 of 5
The nurse is caring for a client who is postoperative day 2 after a bowel resection. Which of the following findings would be of GREATest concern to the nurse?
Correct Answer: A
Rationale: Absence of bowel sounds on postoperative day 2 may indicate paralytic ileus or obstruction, a serious complication requiring immediate evaluation. Options B, C, and D are expected or normal: slight fever is common, incision pain is typical, and urine output is adequate.
Question 4 of 5
An abdominal wound irrigation with a normal saline solution is ordered for a client. To perform this procedure, the nurse should
Correct Answer: B
Rationale: requires strict aseptic technique
Question 5 of 5
A client is receiving a blood transfusion. Fifteen minutes after the transfusion begins, the client develops a fever and chills. Which of the following actions should the nurse take FIRST?
Correct Answer: A
Rationale: fever and chills may indicate a transfusion reaction, and the transfusion must be stopped immediately