NCLEX-PN
NCLEX Trainer Test 2 Questions
Extract:
Question 1 of 5
The nurse is caring for a client who has been placed on a hypothermia blanket. What should the nurse include in the care plan?
Correct Answer: A
Rationale: Frequent vital signs monitor for hypothermia or cardiovascular instability, and skin assessments prevent pressure injuries or cold burns. Direct blanket contact, prolonged use, or alcohol sponges risk skin damage or ineffective cooling.
Question 2 of 5
The nurse is caring for a client who is 6 hours postoperative after an appendectomy. Which of the following findings would be of GREATest concern to the nurse?
Correct Answer: B
Rationale: A temperature of 100.8°F 6 hours post-appendectomy suggests infection, possibly from perforation or abscess, requiring immediate evaluation. Options A, C, and D are expected: heart rate 88 is normal, absent bowel sounds are typical post-surgery, and moderate pain is common.
Question 3 of 5
At 10:00 A.M., the nurse discovers a 75-year-old woman who is hospitalized with congestive heart failure on the floor beside the bed. She has a bruise on her leg, but x-rays reveal no fractures. How should the nurse record the incident in the client's chart?
Correct Answer: B
Rationale: Accurate documentation includes specific details: time, client status, mechanism of fall, assessment findings (bruise size, orientation), and actions taken (physician notification, x-rays). This option is thorough and objective, unlike the others, which are vague or incomplete.
Question 4 of 5
The nurse is teaching a client with a new diagnosis of epilepsy about lamotrigine (Lamictal). Which of the following instructions should the nurse include?
Correct Answer: B
Rationale: A skin rash may indicate Stevens-Johnson syndrome, a serious lamotrigine side effect. Options A, C, and D are incorrect: grapefruit juice is irrelevant, stopping the medication risks seizures, and blood Test s are needed.
Question 5 of 5
The initial response by the nurse to a delusional client who refuses to eat because of a belief that the food is poisoned is
Correct Answer: A
Rationale: You think that someone wants to poison you? This acknowledges the client's perception, opening discussion and expressing doubt.