NCLEX-PN
NCLEX Trainer Test 3 Questions
Extract:
Question 1 of 5
The hospital is planning to downsize and eliminate a number of staff positions as a cost-saving measure. To assist staff in this change process, the nurse manager is preparing for the 'unfreezing' phase of change. With this approach the nurse manager should:
Correct Answer: B
Rationale: Explain to the unit staff why change is necessary. The first phase of change, unfreezing, begins with awareness of the need for change. This can be facilitated by the manager who clearly understands the need and stands behind it.
Question 2 of 5
An older adult is admitted with severe pneumonia. Which of the following measures should the nurse include in the plan of care immediately after admission? Select all that apply.
Correct Answer: A,B,C,D
Rationale: Fluids hydrate and thin secretions, antipyretics control fever, antibiotics treat infection, and mucolytics aid mucus clearance in pneumonia. Ambulation and large meals may be inappropriate initially due to fatigue.
Extract:
A 28-year-old woman at 39-weeks gestation in active labor screams, 'I have to push, I have to push.' The nurse notes that the client is 8 cm dilated.
Question 3 of 5
The nurse should
Correct Answer: D
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) pushing should be discouraged until the second stage of labor (2) would increase discomfort (3) is inappropriate at this time; this is a short, intense period of labor (4) correct-describes transition phase of labor, breathing technique allows patient to control pain and urge to push and promotes adequate oxygenation of fetus
Extract:
Question 4 of 5
A client has just been admitted with portal hypertension. Which nursing diagnosis would be a priority in planning care?
Correct Answer: B
Rationale: Potential complication hemorrhage. Esophageal varices are dilated and tortuous vessels of the esophagus that are at high risk for rupture if portal circulation pressures rise.
Question 5 of 5
An 80 year-old nursing home resident has a temperature of 101.6 degrees Fahrenheit rectally. This is a sudden change in an otherwise healthy client. Which should the nurse assess first?
Correct Answer: C
Rationale: Level of alertness. Assessing the level of consciousness (alert vs. lethargic vs. unresponsive) will help the provider determine the severity of the acute episode. If the client is alert, responses to questions about complaints can be followed-up quickly.