NCLEX-PN
NCLEX Trainer Test 1 Questions
Extract:
Question 1 of 5
The client who is scheduled for a knee replacement asks the nurse why she should donate her own blood before surgery. How should the nurse respond?
Correct Answer: C
Rationale: Autologous blood donation eliminates transfusion-related infection risks, like hepatitis or HIV, ensuring safety during surgery.
Question 2 of 5
The nurse assesses delayed gross motor development in a 3 year-old child. The inability of the child to do which action confirms this finding?
Correct Answer: A
Rationale: Stand on 1 foot. Balancing on one foot is expected by age 3, indicating gross motor delay if absent.
Question 3 of 5
A client admitted with a severe head injury following an MVA is placed on a ventilator, and hyperventilation is maintained. The primary reason for maintaining hyperventilation is:
Correct Answer: D
Rationale: Hyperventilation reduces $\mathrm{CO}_2$, causing cerebral vasoconstriction, which decreases cerebral blood flow and intracranial pressure in head injuries.
Extract:
A client with multiple sclerosis.
Question 4 of 5
The nurse is performing discharge teaching on a client with multiple sclerosis. It is MOST important for the nurse to include which of the following instructions?
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) client is encouraged to ambulate as tolerated (2) correct-overexposure to heat or cold may cause damage related to the changes in sensation (3) client is encouraged to participate in an exercise program to include ROM, stretching, and strengthening exercises (4) client is encouraged to continue usual activities as much as possible, including social activities
Extract:
Question 5 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.