NCLEX-PN
NCLEX Trainer Test 4 Questions
Extract:
Question 1 of 5
The nurse is caring for a client in the coronary care unit. The display on the cardiac monitor indicates ventricular fibrillation. What should the nurse do first?
Correct Answer: C
Rationale: Assess for presence of pulse. Verifying the absence of a pulse confirms ventricular fibrillation before proceeding with treatment.
Question 2 of 5
A client is being treated for paranoid schizophrenia. When the client became loud and boisterous, the nurse immediately placed him in seclusion as a precautionary measure. The client willingly complied. The nurse's action
Correct Answer: A
Rationale: Seclusion should only be used when there is an immediate threat of violence or threatening behavior toward the staff, the other clients, or the client himself.
Question 3 of 5
An adult client who has a fractured tibia is ordered to take one baby aspirin a day. He says to the nurse, 'I don't think the aspirin is doing any good. I still have pain.' What should the nurse include when replying to this client?
Correct Answer: A
Rationale: Low-dose aspirin is used to prevent thrombus formation in immobilized clients with fractures. It's not primarily for fever, pain, or inflammation in this context.
Question 4 of 5
The nurse is evaluating the progress of a client who has had a cerebrovascular accident and realizes there has been limited progress. What should the nurse do?
Correct Answer: B
Rationale: Reassessing goals adjusts the care plan to the client's current abilities, optimizing recovery post-CVA.
Question 5 of 5
The nurse is caring for a client who is postoperative day 1 after a total knee replacement. Which of the following actions is the PRIORITY?
Correct Answer: C
Rationale: Applying the CPM machine is the priority to prevent stiffness and promote joint mobility post-knee replacement. Options A, B, and D are important but secondary: incentive spirometry prevents pneumonia, pain management supports recovery, and dressing checks monitor bleeding.