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 is teaching a client with a new diagnosis of hypertension about lifestyle modifications. Which of the following statements by the client indicates a need for further teaching?
Correct Answer: D
Rationale: Limiting coffee to one cup a day is unnecessary, as moderate caffeine does not significantly affect blood pressure in most hypertensive patients. Options A, B, and C are correct: exercise, low-sodium diet, and smoking cessation reduce blood pressure.
Extract:
An 8-year-old girl has a closed transverse fracture of her right ulna.
Question 3 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
Extract:
Question 4 of 5
A nurse is working in an outpatient orthopedic clinic. During the patient's history the patient reports, 'I tore 3 of my 4 Rotator cuff muscles in the past.' Which of the following muscles cannot be considered as possibly being torn?
Correct Answer: B
Rationale: Teres Minor, Infraspinatus, Supraspinatus, and Subscapularis make up the Rotator Cuff.
Extract:
A 52-year-old woman has an appendectomy for a ruptured appendix. The nurse observes a student nurse perform a wet-to-dry dressing change on the 2-in incision.
Question 5 of 5
Which of the following behaviors, if performed by the student nurse, would require an intervention by the nurse?
Correct Answer: A
Rationale: Strategy: 'Require an intervention' indicates an incorrect action. (1) correct-should be removed dry so wound debris and necrotic tissue are removed with old dressing (2) done to protect clothing and bedding (3) purpose of wet-to-dry dressing (4) appropriate procedure