NCLEX-PN
NCLEX Trainer Test 10 Questions
Extract:
Question 1 of 5
The nurse in a long-term care facility is reviewing the nurse's notes in a client's chart. The nurse would be MOST concerned by which of the following entries?
Correct Answer: B
Rationale: blanching or hyperemia that does not disappear in a short time is a warning sign of pressure ulcers
Question 2 of 5
The nurse is caring for a client with a history of congestive heart failure.
Correct Answer: A
Rationale: Daily weight monitoring detects fluid retention early, a key indicator of worsening heart failure. Extra diuretics require medical orders, high-sodium diets worsen fluid retention, and exercise is encouraged within limits.
Question 3 of 5
The nurse is caring for a toddler in traction, and the toddler is receiving chloral hydrate (Noctec). The toddler becomes irritable and extremely restless. Which nursing action is MOST appropriate?
Correct Answer: B
Rationale: Irritability and restlessness suggest a paradoxical reaction to chloral hydrate, requiring physician notification for medication adjustment. Options A, C, and D are unsafe or ineffective.
Question 4 of 5
A four-week-old infant with symptoms of pyloric stenosis is brought to the outpatient clinic by his mother. Which of the following statements would the nurse expect the mother to make about her son's symptoms?
Correct Answer: C
Rationale: becomes lethargic, dehydrated, and malnourished
Question 5 of 5
The nurse is caring for a schizophrenic client who has become increasingly withdrawn to the point of mutism. The MOST important nursing approach at this time would be to
Correct Answer: B
Rationale: nurse should maintain contact with client but not make demands to communicate or participate in activities