NCLEX-PN
NCLEX Trainer Test 2 Questions
Extract:
Question 1 of 5
The nurse is assigned to a client who has heart failure. During the morning rounds the nurse sees the client develop sudden anxiety, diaphoresis and dyspnea. The nurse auscultates, crackles bilaterally. Which nursing intervention should be performed first?
Correct Answer: B
Rationale: Place the client in a sitting position with legs dangling. This reduces venous return, alleviating pulmonary edema symptoms.
Question 2 of 5
After sustaining a closed head injury and numerous lacerations and abrasions to the face and neck, a five-year-old child is admitted to the emergency room.
Correct Answer: B
Rationale: Clear fluid draining from the ear suggests cerebrospinal fluid (CSF) leakage due to a meningeal rupture, a serious complication that risks meningitis and requires immediate reporting. Eyelid edema, minor bleeding, and withdrawal to pain are less urgent or expected findings.
Question 3 of 5
The nurse is caring for a client who is receiving IV vancomycin for a methicillin-resistant Staphylococcus aureus (MRSA) infection. Which of the following findings would be of GREATest concern to the nurse?
Correct Answer: C
Rationale: Facial flushing and itching suggest red man syndrome, a serious reaction to vancomycin, requiring immediate slowing of the infusion or antihistamine administration. Options A, B, and D are normal: blood pressure 130/80 mmHg, heart rate 90 bpm, and urine output 50 mL/hour are stable.
Extract:
A 75-year-old man following a right total hip replacement. The nurse's notes indicate that since the surgery the patient has become disoriented and confused at night. One evening as the nurse prepares the patient for sleep, the patient glances to his left and says, 'Oh, you think so?' and starts to laugh.
Question 4 of 5
Which of the following responses by the nurse is the BEST?
Correct Answer: D
Rationale: Strategy: Remember therapeutic communication. (1) yes/no question, may make client defensive and block communication (2) feeds into client's altered-reality state, nurse should suspect a hallucination (3) confrontation would block communication (4) correct-therapeutic statement of client's nonverbal communication
Extract:
A client receiving cromolyn sodium (Intal).
Question 5 of 5
Which of the following statements, if made by the client to the nurse, indicates that teaching has been successful?
Correct Answer: D
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) inappropriate information (2) inappropriate information (3) cromolyn sodium is not an antihistamine agent, an antiinflammatory, or a bronchodilator, does nothing for a client in respiratory distress (4) correct-cromolyn sodium (Intal) is used to prevent the release of histamine and other allergy-triggering substances