NCLEX-PN
NCLEX Trainer Test 2 Questions
Extract:
Question 1 of 5
The greatest threat during the immediate post-burn period results from burn shock. Which of the following statements best describes why burn shock occurs?
Correct Answer: A
Rationale: Burn shock occurs due to histamine release causing vasodilation and increased capillary permeability, leading to fluid loss from the vascular to interstitial space.
Extract:
A 75-year-old man following a right total hip replacement. The nurse's notes indicate that since the surgery the patient has become disoriented and confused at night. One evening as the nurse prepares the patient for sleep, the patient glances to his left and says, 'Oh, you think so?' and starts to laugh.
Question 2 of 5
Which of the following responses by the nurse is the BEST?
Correct Answer: D
Rationale: Strategy: Remember therapeutic communication. (1) yes/no question, may make client defensive and block communication (2) feeds into client's altered-reality state, nurse should suspect a hallucination (3) confrontation would block communication (4) correct-therapeutic statement of client's nonverbal communication
Extract:
A client is diagnosed with lung cancer and undergoes a pneumonectomy.
Question 3 of 5
In the immediate postoperative period, which of the following nursing assessments is MOST important?
Correct Answer: B
Rationale: Strategy: Determine how each answer choice relates to a pneumonectomy. (1) on the surgical side, breath sounds will be absent (2) correct-position of the trachea should be evaluated; with a tracheal shift, an increase in pressure could occur on the operative side and could cause pressure against the mediastinal area (3) important to observe but not as high a priority (4) does not relate to the situation
Extract:
Question 4 of 5
The nurse is teaching parents of a 7 month-old about adding table foods. Which of the following is an appropriate finger food?
Correct Answer: B
Rationale: Sliced bananas. Finger foods should be bite-size pieces of soft food such as bananas. Hot dogs and grapes can accidentally be swallowed whole and-mile occlude the airway. Popcorn is too difficult to chew at this age and can irritate the airway if swallowed.
Question 5 of 5
A client is to begin taking Fosamax. The nurse must emphasize which of these instructions to the client when taking this medication? 'Take Fosamax
Correct Answer: A
Rationale: Fosamax should be taken first thing in the morning with 6-8 ounces of plain water at least 30 minutes before other medication or food. Food and fluids (other than water) greatly decrease the absorption of Fosamax. The client must be instructed to remain in the upright position for 30 minutes following the dose to facilitate passage into the stomach and minimize irritation of the esophagus.