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.
Question 2 of 5
A new nurse manager is responsible for interviewing applicants for a staff nurse position. Which interview strategy would be the best approach?
Correct Answer: C
Rationale: Obtain an interview guide from human resources for consistency in interviewing each candidate. An interview guide used for each candidate enables the nurse manager to be more objective in the decision making. The nurse should use resources available in the agency before attempts to develop one from scratch. Certain personal questions are prohibited, and HR can identify these for novice managers.
Question 3 of 5
The nurse is caring for a newborn with tracheoesophageal fistula. Which nursing diagnosis is a priority?
Correct Answer: B
Rationale: The most common form of TEF is one in which the proximal esophageal segment terminates in a blind pouch and the distal segment is connected to the trachea or primary bronchus by a short fistula. Thus, a priority is maintaining an open airway, preventing aspiration.
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 4 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 5 of 5
The nurse is caring for a client who is receiving IV fluids at 125 mL/hour. Which of the following findings would be of GREATest concern to the nurse?
Correct Answer: C
Rationale: A respiratory rate of 24 breaths/min suggests fluid overload, a potential complication of IV fluids, possibly leading to pulmonary edema. Options A, B, and D are normal: blood pressure 130/80 mmHg, heart rate 88 bpm, and urine output 100 mL/hour indicate adequate hydration.