NCLEX-PN
NCLEX Trainer Test 9 Questions
Extract:
Question 1 of 5
The nurse is auscultating the chest of a client with heart failure. The nurse should assess for which finding as an early sign of volume overload?
Correct Answer: A
Rationale: S3 heart sound. This is an early sign of volume overload due to fluid in the ventricles during diastole.
Question 2 of 5
The nurse is caring for a client with a history of anaphylaxis.
Correct Answer: A
Rationale: Carrying an epinephrine auto-injector is critical for immediate treatment of anaphylaxis, a life-threatening allergic reaction. Avoiding medications, wearing loose clothing, and monitoring blood pressure are less urgent.
Question 3 of 5
The nurse discovers that a hospitalized client is not breathing and has no pulse. After calling for help, what should the nurse do next?
Correct Answer: A
Rationale: Per CPR guidelines, after calling for help, provide two rescue breaths if trained, followed by compressions. Fetching the cart or defibrillating delays resuscitation.
Question 4 of 5
All of the following clients need care. Who should the nurse see first?
Correct Answer: A
Rationale: A blood sugar of 40 indicates severe hypoglycemia, a life-threatening emergency requiring immediate intervention. Pain complaints are less urgent.
Extract:
A client one day after a thoracotomy.
Question 5 of 5
Nursing actions on the care plan include: turn, cough, and deep breathe q2h. The nurse understands that the purpose of this nursing action is to
Correct Answer: A
Rationale: Strategy: Think about each answer choice. (1) correct-primary purpose of this nursing measure is to improve and/or maintain good gas exchange, especially removal of carbon dioxide in order to prevent respiratory acidosis (2) answer choice #1 is better in that it refers to ventilation rather than oxygenation (3) increasing the pH is not desirable (4) respiratory alkalosis is not prevented by this nursing measure