NCLEX-PN
NCLEX Trainer Test 5 Questions
Extract:
Question 1 of 5
The nurse is caring for a 79-year-old client. Which observation is not normal and should be reported for follow-up?
Correct Answer: C
Rationale: Shortness of breath with exertion may indicate cardiovascular or respiratory issues, requiring follow-up. Brown spots, slower movement, and color vision changes are normal aging signs.
Question 2 of 5
When assessing a client who has just undergone a cardioversion, the practical nurse (LPN) finds the respirations are 12/minute. Which action should the nurse take first?
Correct Answer: D
Rationale: Continue to monitor respirations. A rate of 12/minute is acceptable post-cardioversion, requiring no immediate intervention.
Question 3 of 5
A client returns from surgery after an open reduction of a femur fracture. There is a small bloodstain on the cast. Four hours later, the nurse observes that the stain has doubled in size. What is the best action for the nurse to take?
Correct Answer: D
Rationale: Outline the spot with a pencil and note the time and date on the cast. This is a good way to assess the amount of bleeding over a period of time. The bleeding does not appear to be excessive and some bleeding is expected with this type of surgery. The bleeding should also be documented in the nurse's notes.
Question 4 of 5
An adult is admitted to the unit with a fractured femur and will be in Buck's extension traction for several days. The client tells the nurse that she has all of the following. Which is likely to cause the client the most problems at this time?
Correct Answer: B
Rationale: Hiatal hernia can be exacerbated by prolonged immobility in traction, increasing reflux and discomfort. Hypertension, finger osteoarthritis, and high cholesterol are less directly impacted by traction.
Question 5 of 5
The nurse is caring for a client with a history of falls.
Correct Answer: C
Rationale: A night light in the bathroom reduces fall risk by improving visibility during nighttime ambulation, a common time for falls. High bed positions and bed rest increase fall risk, and fluid restriction is unrelated to fall prevention.