NCLEX-PN
NCLEX Trainer Test 1 Questions
Extract:
Question 1 of 5
The nurse is caring for a client who had a stroke and is experiencing dysphagia. Which of the following nursing actions is the PRIORITY?
Correct Answer: A
Rationale: Positioning the client upright during meals reduces the risk of aspiration, a life-threatening complication in dysphagia. Options B, C, and D are inappropriate: thin liquids increase aspiration risk, soft diets are secondary, and eating quickly exacerbates the problem.
Extract:
A client is admitted to the neurology unit for a myelogram.
Question 2 of 5
It would be MOST important for the nurse to ask which of the following questions?
Correct Answer: A
Rationale: Strategy: Think about each answer choice and how it relates to a myelogram. (1) correct-dye is injected into subarachnoid space before an x-ray of spinal cord and vertebral column to assist in identifying spinal lesions; if client is allergic to dye, there is a major safety issue (2) important that client drink extra fluids after the Test to replace the CSF lost during Test (3) appropriate for magnetic resonance imaging (MRI) (4) obtain history of medication that can lower seizure threshold (phenothiazines, neuroleptics)
Extract:
Question 3 of 5
The nurse is caring for an adult who has had nausea and vomiting for several days and is being admitted to the nursing care unit. The client can follow directions. IV fluids were started in the emergency department. Which action is the highest priority for the nurse at this time?
Correct Answer: C
Rationale: Monitoring urine output is critical to assess hydration status and kidney function in a client with prolonged nausea and vomiting, as dehydration is a major risk. IV fluids address dehydration, making oral fluids less urgent, and turning or positioning are secondary.
Extract:
A 46-year-old man with newly diagnosed diabetes mellitus.
Question 4 of 5
Which of the following responses by the nurse is BEST?
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) should buy shoes in the afternoon when feet are larger than in the morning (2) correct-feet enlarge with age, don't break in shoes all at one time, have measurements for shoes taken while standing (feet are larger) (3) buy correct shoe size (4) leather shoes recommended because they 'breathe', vinyl could cause foot to perspire and aggravate fungal infections
Extract:
Question 5 of 5
The nurse is caring for a client with a history of spinal cord injury.
Correct Answer: C
Rationale: Keeping the bladder empty prevents distension, a common trigger for autonomic dysreflexia, a life-threatening hypertensive crisis in spinal cord injury. Blood pressure monitoring detects it, analgesics are irrelevant, and high-fiber diets prevent constipation.