NCLEX-PN
NCLEX Trainer Test 1 Questions
Extract:
Question 1 of 5
The nurse is caring for a client who is postoperative day 1 after a gastrectomy. Which of the following findings would be of GREATest concern to the nurse?
Correct Answer: A
Rationale: A temperature of 100.8°F suggests infection, a serious complication post-gastrectomy due to risk of anastomotic leak, requiring immediate evaluation. Options B, C, and D are expected: incision pain, NG tube output, and urine output 40 mL/hour are normal on day 1.
Extract:
A client that has stage III pressure ulcer of the sacrum with foul smelling purulent drainage.
Question 2 of 5
The nurse should intervene in which of the following situations?
Correct Answer: B
Rationale: Strategy: 'Nurse should intervene' indicates an incorrect behavior. All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) contact precautions required for infected decubitus ulcer; private room if possible (2) correct-masks not needed and doors do not need to be closed (3) maintain positive nitrogen balance, should offer high protein diet with protein supplements (4) lifting prevents shearing force
Extract:
An older woman hospitalized with a fractured left hip, placed in Buck's traction with a seven-pound weight while awaiting surgery.
Question 3 of 5
Which of the following instructions for moving should be discussed by the nurse to encourage the patient to participate in her care?
Correct Answer: A
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct-body must move as single, straight unit (2) turning or twisting from the waist down interferes with countertraction (3) prevents proper pull of weights (4) can't turn from side to side, can only move up and down
Extract:
Question 4 of 5
The nurse is caring for a client with a complete heart block. The nurse should question which of the following orders?
Correct Answer: A
Rationale: Lidocaine suppresses ventricular activity, which could worsen complete heart block by reducing the ventricular escape rhythm. Options B, C, and D are appropriate: atropine increases heart rate, pacemakers treat persistent bradycardia, and isoproterenol supports severe bradycardia.
Question 5 of 5
A teen hospitalized with anorexia nervosa is now permitted to leave her room and eat in the dining room. Which of the following nursing interventions should be included in the client's plan of care?
Correct Answer: B
Rationale: Having a staff member stay with the client for 1 hour after eating prevents purging, a common behavior in anorexia nervosa.