NCLEX-PN
NCLEX Trainer Test 4 Questions
Extract:
During auscultation of the fetal heart rate during labor, the nurse assesses a rate of 59 beats per minute.
Question 1 of 5
The FIRST action the nurse should take is
Correct Answer: B
Rationale: Strategy: 'FIRST' indicates that this is a priority question. All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) should be placed on left side to increase blood flow to the uterus (2) correct-persistent fetal bradycardia may indicate cord compression or separation of the placenta, but always indicates fetal distress, left side reduces compression of vena cava and aorta (3) should be done after positioning patient (4) this position is used only if there is cord prolapsed
Extract:
Question 2 of 5
The nurse auscultates bibasilar inspiratory crackles in a newly admitted 68 year-old client with a diagnosis of congestive heart disease. Which other finding is most likely to occur?
Correct Answer: B
Rationale: Peripheral edema. Bibasilar crackles and peripheral edema are common in congestive heart failure due to fluid overload.
Question 3 of 5
Triage refers to the classification of injury severity during a disaster. Which of the following clients should receive priority during triage?
Correct Answer: B
Rationale: Burns to the head and neck are prioritized due to potential airway compromise, a life-threatening condition. Open fractures, crushing injuries, and minor head injuries are less immediately critical.
Extract:
A client is being treated for hypovolemia.
Question 4 of 5
Which of the following observations should the nurse identify as the desired response to fluid replacement?
Correct Answer: D
Rationale: Strategy: Determine the significance of each answer choice and how it relates to hypovolemia. (1) indicates a hypovolemic state (2) indicates a hypovolemic state (3) indicates acidosis (4) correct-normal range for CVP is 3-8 cm water pressure (or 2-6 mm Hg); reading of 8 cm water pressure would indicate a desired response to fluid replacement
Extract:
An 8-year-old girl has a closed transverse fracture of her right ulna.
Question 5 of 5
Which of the following actions, if performed by the nurse before the application of a cast, is MOST important?
Correct Answer: A
Rationale: Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. (1) correct-assess neurovascular status, check pain, pallor, paralysis, paresthesia, pulselessness (2) assessment, temperature indicates decreased circulation, but is subjective and not most important (3) assessment, upper (not lower) extremity fracture (4) implementation, should not be done because it would increase skin irritation