NCLEX-PN
NCLEX Trainer Test 7 Questions
Extract:
Question 1 of 5
The client is being admitted for surgery. During the admission assessment, the client states that she usually has 8 to 10 alcoholic drinks a day. How should the nurse reply?
Correct Answer: C
Rationale: Admitting to 8 to 10 alcoholic drinks a day is suggestive of alcoholism. It is important to know when the client last had a drink of alcohol in order to anticipate the onset of withdrawal symptoms. The type of alcohol the client drinks, how long the client has been drinking, and why the client drinks are not the key issues. The key issue is when to anticipate withdrawal symptoms.
Question 2 of 5
The home care nurse has been managing a client for 6 weeks. What is the best method to determine the quality of care provided by a home health care aide assigned to assist with the care of this client?
Correct Answer: B
Rationale: Although the nurse must complete all of the above responsibilities, evaluation of an adherence to the plan of care is the first priority. The plan of care is based on the reason for referral, provider's orders, the initial nursing assessment, the client's responses to the planned interventions, and the client's and family's feedback or inquiries.
Extract:
A primigravida client, 10-days postpartum, who is anxious about caring for her newborn. A middle-aged client, 6-days postoperative, who is complaining of pain in his midsternal incision. A client with AIDS who had a chest tube removed yesterday and is complaining of crackling under his skin. A client who receives amiloride hydrochloride (Midamor) and states that she is dizzy when she gets up in the morning.
Question 3 of 5
The homecare nurse is scheduling clients for the day. Which of the following clients should the nurse visit FIRST?
Correct Answer: C
Rationale: Strategy: Identify the least stable client by eliminating the more stable clients. (1) psychosocial need, physical issues take priority (2) complaints require follow-up, but not the most unstable client (3) correct-describes subcutaneous emphysema, which is indication of pneumothorax; observe client for respiratory distress, contact physician (4) postural hypotension a side effect of diuretic therapy, change position slowly
Extract:
A client after an electroconvulsive therapy (ECT) treatment.
Question 4 of 5
The nurse should report which observation to the client's physician?
Correct Answer: D
Rationale: Strategy: You are looking for something unexpected. (1) expected effect (2) expected effect (3) expected effect (4) correct-client undergoing ECT needs to be instructed about what s/he could experience during and after ECT; expected effects include headache, disrupted memory (short- and long-term), and general confused state; backache is not a usual effect; thorough description of the pain in relation to severity, duration, location, and what makes pain better needs to be assessed and reported to the physician
Extract:
Question 5 of 5
While a client is receiving TPN, it is MOST important for the nurse to monitor
Correct Answer: C
Rationale: TPN can cause hyperglycemia and electrolyte imbalances, making serum glucose and electrolyte monitoring critical. Options A, B, and D are less specific.