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
An older adult is diagnosed with Parkinson's disease. The client asks the nurse what causes Parkinson's disease. In addition to telling the client that we are not really sure what causes it, the nurse should include which information?
Correct Answer: A
Rationale: Parkinson's disease results from dopamine deficiency in the basal ganglia, impairing movement, unlike myelin destruction, acetylcholine issues, or circulatory obstruction.
Question 3 of 5
For which of the following mother-baby pairs should the nurse review the Coombs' test in preparation for administering Rh0 (D) immune globulin within 72 hours of birth?
Correct Answer: A
Rationale: Rh negative mother with Rh positive baby. Rh0 (
D) immune globulin is administered to prevent Rh sensitization in an Rh-negative mother who may have been exposed to Rh-positive fetal blood during delivery. The Coombs' test helps determine if the baby is Rh-positive, confirming the need for the injection.
Question 4 of 5
A 78-year-old client is admitted in heart failure. Which assessment is essential for the nurse to make because the client is in heart failure? Select all that apply.
Correct Answer: B,D,E
Rationale: Persons who are in heart failure are at risk for developing pulmonary edema. The nurse should listen for lung sounds, check legs for pitting edema, which is common in heart failure, and observe respirations for severe dyspnea. Pedal pulses, upper extremity neuro checks, and gait disturbances are not related to heart failure or to pulmonary edema.
Extract:
A client had a radical mastectomy for cancer in her right breast.
Question 5 of 5
After the client returns to the unit, which of the following actions, if performed by the nurse, would be MOST appropriate?
Correct Answer: C
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) sling is not necessary, arm needs to be elevated (2) right arm cannot be elevated from this position (3) correct-this position will facilitate removal of fluid from venous pathways and lymphatic system through gravity; arm is elevated to enhance circulation and prevent edema (4) prone position is not appropriate