NCLEX-PN
NCLEX Trainer Test 3 Questions
Extract:
A client has a nasogastric tube in place after extensive abdominal surgery. The client complains of nausea. His abdomen is distended, and there are no bowel sounds.
Question 1 of 5
The FIRST nursing action should be to
Correct Answer: C
Rationale: Strategy: Answers are a mix of assessments and implementations. Is this a situation that requires assessment? Yes. (1) implementation, may be carried out after the patency of the tube is determined (2) implementation, patency should be checked first (3) correct-should first assess if the tube is open and draining to determine if there is a problem with the nasogastric tube; if it is patent and draining it does not need to be irrigated (4) assessment, patency should be checked first by aspirating stomach contents, not by auscultation
Extract:
Question 2 of 5
The nurse is teaching a community group about healthy lifestyles to prevent cancer and heart disease. Which comment by a member of the group indicates a need for more teaching?
Correct Answer: C
Rationale: Daily walking strengthens the heart, reducing cardiovascular risk, not straining it. The other statements align with healthy lifestyle practices.
Question 3 of 5
The nurse is caring for an 11-year-old patient being treated for a fractured right femur with balanced suspension traction with a Thomas splint and Pearson attachment.
Correct Answer: A
Rationale: A trochanter roll placed on the outer aspect of the thigh prevents external rotation by holding the hip in a neutral position and maintaining normal leg alignment. Resistive exercises, manual repositioning, or instructing the patient to maintain position are less effective, as they do not provide sustained support to prevent rotation.
Question 4 of 5
A client is admitted to a voluntary hospital mental health unit due to suicidal ideation. The client has been on the unit for 2 days and now states 'I demand to be released now!' The appropriate response from the nurse is
Correct Answer: C
Rationale: Clients voluntarily admitted to the hospital have a right to demand and obtain release. Discussing the decision initially allows an opportunity for other interventions.
Question 5 of 5
An adult client became incontinent while hospitalized. The client now drinks very little. The nurse understands that this is:
Correct Answer: A
Rationale: Reduced fluid intake is a coping strategy to avoid incontinence, though it risks dehydration, reflecting an attempt to manage embarrassment.