NCLEX-PN
NCLEX Trainer Test 5 Questions
Extract:
Question 1 of 5
The nurse is caring for a client on complete bed rest. Which action by the nurse is most important in preventing the formation of deep vein thrombosis?
Correct Answer: D
Rationale: Preventing popliteal pressure will prevent venous stasis and possibly deep vein thrombosis.
Question 2 of 5
The nurse is to administer a nasogastric tube feeding to a client. Which action is essential prior to administering the feeding?
Correct Answer: B
Rationale: Aspirating and checking pH confirms nasogastric tube placement in the stomach, preventing aspiration during feeding.
Question 3 of 5
One hour after receiving 7 U of regular insulin, the client presents with diaphoresis, pallor, and tachycardia. The priority nursing action would be to
Correct Answer: C
Rationale: Diaphoresis, pallor, and tachycardia indicate hypoglycemia, a medical emergency. Milk and crackers provide fast-acting carbohydrates. Options A, B, and D delay treatment or are reserved for severe cases.
Question 4 of 5
A nurse is assessing a patient in the rehab unit at shift change. The patient has suffered a TBI 3 weeks ago. Which of the following is the most distinguishing characteristic of a neurological disturbance?
Correct Answer: A
Rationale: LOC is the most critical indicator of impaired neurological capabilities.
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.