NCLEX-PN
NCLEX Trainer Test 4 Questions
Extract:
A client with right-sided weakness.
Question 1 of 5
The nurse in the outpatient clinic teaches a client with right-sided weakness to walk down stairs using a cane. What behavior, if demonstrated by the client, would indicate that teaching was successful?
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) to go down stairs, advance weak leg and cane first; to go up stairs, advance strong leg, then weak leg and cane (2) correct-to do down stairs, advance cane and weak leg, then strong leg; memory trick: the good goes up, the bad goes down (3) should advance cane and weak leg first (4) weaker leg and cane advance first
Extract:
Question 2 of 5
The nurse is teaching unlicensed personnel about preventing the spread of disease in the health care environment. The nurse knows that the personnel understand when they state that which is the most important way to prevent the spread of disease?
Correct Answer: B
Rationale: Hand washing is the most effective way to prevent disease transmission, breaking the chain of infection in healthcare settings.
Question 3 of 5
The nurse is preparing to administer an injection of haloperidol decanoate (Haldol D).
Correct Answer: B
Rationale: Haloperidol decanoate is highly irritating to subcutaneous tissue, requiring deep IM injection into a large muscle mass to ensure proper absorption and minimize irritation. Massaging the site, using a small-gauge needle, or dividing doses is inappropriate.
Question 4 of 5
When suctioning a client's tracheostomy, the nurse should instill saline in order to
Correct Answer: D
Rationale: remove a mucus plug. While no longer recommended for routine suctioning, saline may thin and loosen viscous secretions that are very difficult to move, perhaps making them easier to suction.
Question 5 of 5
An adult who was struck by lightning is brought to the emergency department. Which action is of highest priority when the client is brought to the emergency room?
Correct Answer: A
Rationale: Lightning strikes can cause cardiac arrhythmias; obtaining an ECG is the highest priority to detect life-threatening rhythm disturbances. Gases, wounds, and electrolytes are secondary.