NCLEX-PN
NCLEX Trainer Test 4 Questions
Extract:
Question 1 of 5
The nurse is caring for a client who had a total gastrectomy performed this morning. When the client returns to the nursing care unit, the drainage from the nasogastric tube is red. What is the nurse's best response to this?
Correct Answer: A
Rationale: Red nasogastric drainage post-gastrectomy suggests bleeding, requiring immediate reporting to assess for hemorrhage.
Extract:
The nurse is admitting a client to the unit from the postoperative recovery area after abdominal exploratory surgery.
Question 2 of 5
After determining the client's vital signs, which of the following activities should the nurse perform next?
Correct Answer: C
Rationale: Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. (1) implementation, complete assessment first (2) assessment, determine what is happening to the patient now (3) correct-assessment, dressing should be checked on admission to the room and frequently for the next several hours (4) inappropriate assessment, it is too soon for infection to occur secondary to surgery
Extract:
An elderly client who has just had a prosthetic hip implant.
Question 3 of 5
The nurse should position the client
Correct Answer: D
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) flexion beyond 60°, adduction and internal rotation should be avoided in the early postoperative period (2) flexion beyond 60°, adduction and internal rotation should be avoided in the early postoperative period (3) flexion beyond 60°, adduction and internal rotation should be avoided in the early postoperative period (4) correct-position of abduction should be maintained
Extract:
Question 4 of 5
The doctor has ordered the removal of a Davol drain. Which of the following instructions should the nurse give to the client prior to removing the drain?
Correct Answer: C
Rationale: Holding the breath during Davol drain removal prevents air entry into the wound. Normal breathing , deep breaths , or slow breathing may increase complications.
Question 5 of 5
The nurse is caring for a client with a history of type 1 diabetes who is receiving insulin detemir (Levemir) 15 units SC daily. Which of the following symptoms should the nurse report immediately?
Correct Answer: B
Rationale: Sweating and shakiness indicate hypoglycemia, a medical emergency with insulin detemir. Options A, C, and D are less urgent: fatigue is nonspecific, thirst is expected, and headache is common.