NCLEX-PN
NCLEX Trainer Test 6 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 should the nurse report immediately?
Correct Answer: A
Rationale: Absence of bowel sounds on day 2 suggests ileus or obstruction, requiring immediate reporting. Options B, C, and D are expected or normal.
Question 2 of 5
Which of the following findings is consistent with a diagnosis of congestive heart failure?
Correct Answer: A
Rationale: Jugular vein distention reflects increased fluid volume and right-sided heart failure, a hallmark of congestive heart failure. Other options are not specific to this condition.
Extract:
A postoperative client has returned to his room from the surgical recovery area. The client is sleeping, and the nurse notes that the client is disoriented when aroused.
Question 3 of 5
Which of the following actions, if taken by the nurse, is BEST?
Correct Answer: D
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) not the safety action (2) unnecessary to stay with the client, especially while he is sleeping (3) restraints are unnecessary at this time (4) correct-side rails should always be elevated for any disoriented client
Extract:
Question 4 of 5
While caring for a child who had a revision of a ventriculoperitoneal shunt, the nurse notes clear drainage from the incision. Which of the following actions should the nurse take first?
Correct Answer: C
Rationale: Clear drainage may indicate cerebrospinal fluid (CSF) leak; checking for glucose with a Dextrostik confirms CSF, which requires immediate action.
Extract:
A two-day-old infant in the newborn nursery does not appear interested in taking formula from the mother or the nurse.
Question 5 of 5
An appropriate nursing diagnosis is high risk for
Correct Answer: C
Rationale: Strategy: Think about each answer choice. (1) no information about swallowing provided with question (2) this is a medical diagnosis not a nursing diagnosis (3) correct-may become dehydrated (4) not specific for problem described