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.
Question 2 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.
Question 3 of 5
The nurse is caring for a client who is to be on bed rest for two weeks. What should the nurse do to prevent atelectasis?
Correct Answer: A
Rationale: Deep breathing and coughing expand the lungs, preventing atelectasis in bedridden clients. Foot exercises, stockings, and ROM prevent other complications but not atelectasis.
Question 4 of 5
Parents are concerned that their 11 year-old child is a very picky eater. The nurse suggests which of the following as the best initial approach?
Correct Answer: B
Rationale: Discuss consequences of an unbalanced diet with the child. It is important to educate the preadolescent as to appropriate diet, and the problems that might arise if diet is not adequate.
Question 5 of 5
A client admitted with a severe head injury following an MVA is placed on a ventilator, and hyperventilation is maintained. The primary reason for maintaining hyperventilation is:
Correct Answer: D
Rationale: Hyperventilation reduces $\mathrm{CO}_2$, causing cerebral vasoconstriction, which decreases cerebral blood flow and intracranial pressure in head injuries.