NCLEX-PN
NCLEX Trainer Test 4 Questions
Extract:
Question 1 of 5
The nurse is caring for a client who is post-op following a thoracotomy. The client has 2 chest tubes in place, connected to 1 chest drain. The nursing assessment reveals bubbling in the water seal chamber when the client coughs. What is the most appropriate nursing action?
Correct Answer: C
Rationale: Bubbling associated with coughing after lung surgery is to be expected as small amounts of air escape the pleural space when pressures inside the chest increase with coughing. Monitoring is the only nursing action required at this time.
Extract:
A patient is admitted to the hospital for a hypoglossectomy with lymph node dissection.
Question 2 of 5
The patient's preoperative care includes frequent oral hygiene with hydrogen peroxide. The nurse knows the purpose of this treatment is to
Correct Answer: A
Rationale: Strategy: Determine how each answer choice relates to the procedure. (1) correct-destroys bacteria found in mouth, reduces the chance of infection (2) is not the action of hydrogen peroxide (3) circulation is unaffected by a mouth rinse (4) has slight drying effect on mucous membranes
Extract:
Question 3 of 5
The nurse is caring for an adult who is enrolled in a study involving an experimental drug. The client says to the nurse, 'I don't think I can stand the vomiting anymore. I think it is due to the drug I am taking. If only I could get out of this study I signed up for. That was a really stupid thing I did when I signed up for the study.' What information must the nurse include when responding to the client?
Correct Answer: B
Rationale: Participants can withdraw from research studies at any time, per ethical research guidelines, ensuring autonomy and safety.
Question 4 of 5
The nurse is caring for a client with a history of ulcerative colitis.
Correct Answer: B
Rationale: A white blood cell count of 15,000/mm³ suggests infection or severe inflammation in ulcerative colitis, requiring immediate attention. Low hemoglobin and albumin are common, and normal potassium is unremarkable.
Question 5 of 5
A client hospitalized with bipolar disorder, manic phase, begins to talk loudly, pace the floor, and shout commands to others in the day room as he quickly changes the TV channels. The nurse's first action should include:
Correct Answer: B
Rationale: Escorting the client from the day room de-escalates the situation by removing them from a stimulating environment, reducing agitation.