NCLEX-PN
NCLEX Trainer Test 3 Questions
Extract:
Question 1 of 5
The nurse in a long-term care facility wants to help a resident become continent of stools. Which is likely to be most helpful when planning care for the resident? Select all that apply.
Correct Answer: A,C,D
Rationale:
Toileting after meals leverages the gastrocolic reflex, fluids soften stool, and walking stimulates peristalsis, all promoting continence. Limiting fiber, listing foods, or discouraging snacking are less effective or counterproductive.
Extract:
A client who has had an above-knee amputation (AKA) with an immediate prosthetic fitting.
Question 2 of 5
It is MOST important for the nurse to
Correct Answer: D
Rationale: Strategy: Answers are a mix of assessments and implementations. Is there an appropriate assessment? No. Determine the outcome of each implementation. (1) drains not usually used with amputations (2) rigid cast dressing frequently used to create a socket for prosthesis (3) elevation of extremity unnecessary, rigid cast dressing prevents swelling (4) correct-cast applied to provide uniform compression, prevent pain and contractures
Extract:
Question 3 of 5
Docusate sodium (Colace) is ordered for an adult who had a myocardial infarction yesterday. The client asks the nurse why docusate sodium is prescribed. The nurse's response should include which information?
Correct Answer: D
Rationale: Docusate sodium is a stool softener, reducing straining during bowel movements, which decreases cardiac strain post-MI.
Question 4 of 5
The nurse is caring for a client with a history of depression who is receiving sertraline (Zoloft) 50 mg PO daily. Which of the following client statements would be of GREATest concern to the nurse?
Correct Answer: C
Rationale: Thoughts of self-harm indicate suicidal ideation, a medical emergency requiring immediate intervention in a client on sertraline. Options A, B, and D are common side effects of SSRIs (fatigue, insomnia, dry mouth) and less urgent.
Question 5 of 5
The registered nurse has just admitted a client with severe depression. What domain should be the priority focus as the nurse identifies the nursing diagnoses?
Correct Answer: D
Rationale: Safety. A depressed client is at acute risk for self-destructive behavior, making safety the priority.