NCLEX-PN
NCLEX Trainer Test 10 Questions
Extract:
Question 1 of 5
The nurse is caring for a client who is postoperative day 2 after a bowel resection. Which of the following findings would be of GREATest concern to the nurse?
Correct Answer: A
Rationale: Absence of bowel sounds on postoperative day 2 may indicate paralytic ileus or obstruction, a serious complication requiring immediate evaluation. Options B, C, and D are expected or normal: slight fever is common, incision pain is typical, and urine output is adequate.
Question 2 of 5
Which of the following nursing actions has the HIGHEST priority for a teenager admitted with burns to 50% of his body?
Correct Answer: C
Rationale: A teenager with 50% body burns is at high risk for infection due to loss of skin barrier. Maintaining aseptic technique during procedures is the highest priority to prevent life-threatening infections. Counseling, precautions, and peer visits are important but secondary to infection control.
Question 3 of 5
The lab reports a lecithin/sphingomyelin (L/S) ratio of 3:1 for a client who has been on bedrest 48 hours in an unsuccessful attempt to arrest premature labor at 33-weeks gestation. Based on this result, the nurse would anticipate
Correct Answer: C
Rationale: because the lungs are adequately mature, there is no need to attempt to postpone labor; delivery by cesarean section is generally preferred for preterm infants
Question 4 of 5
The nurse is caring for a 22-year-old woman who is completing the first stage of labor. The woman's husband is at her side and has been coaching her according to exercises they learned at natural childbirth classes. Suddenly the woman begins to shake and screams, 'I can't stand this anymore!' The nurse should encourage the husband to
Correct Answer: A
Rationale: entering transition phase of first stage of labor, slow shallow breaths needed (pant breathing)
Question 5 of 5
A client is admitted for treatment of severe anxiety. It is MOST important for the nurse to obtain which of following information during the first 48 hours after admission?
Correct Answer: C
Rationale: will provide necessary information in baseline assessment of client's anxiety