NCLEX-PN
NCLEX Trainer Test 7 Questions
Extract:
Question 1 of 5
The nurse is caring for a client who is receiving a blood transfusion. Which of the following findings would be of GREATest concern to the nurse?
Correct Answer: A
Rationale: A temperature of 100.4°F during a blood transfusion suggests a transfusion reaction, such as febrile non-hemolytic reaction, requiring immediate cessation of the transfusion. Options B, C, and D are normal: heart rate 90 bpm, respiratory rate 18 breaths/min, and blood pressure 120/80 mmHg do not indicate complications.
Question 2 of 5
A husband and wife meet at the mental health clinic to make an appointment for family therapy. Suddenly, the wife begins to sob loudly. As the nurse approaches, the husband says, 'I guess we just don't get along.' Which of the following responses by the nurse is MOST appropriate?
Correct Answer: D
Rationale: Acknowledging the emotional impact on both spouses fosters therapeutic communication without judgment. Options A, B, and C are less effective: A focuses only on the wife, B dismisses the situation, and C may provoke defensiveness.
Extract:
A client experiencing alcohol withdrawal.
Question 3 of 5
Which finding would indicate to the nurse that a client experiencing alcohol withdrawal is in need of more sedation to control the severity of withdrawal symptoms?
Correct Answer: C
Rationale: Strategy: Determine the significance of each answer choice and how it relates to alcohol withdrawal. (1) would indicate a need for less sedation and a thorough physical assessment (2) suggests neurological trauma or damage (3) correct-pulse rate is a good indicator of client's progress through withdrawal, increasingly elevated pulse signals impending alcohol withdrawal delirium, requiring more sedation (4) suggests that the client is improving and will subsequently require less sedation
Extract:
Question 4 of 5
The client says to the nurse, 'I don't see why I should live any longer.' How should the nurse respond initially?
Correct Answer: B
Rationale: Expressing a desire to not live suggests suicidal ideation; directly asking about suicide assesses risk and guides intervention. Exploring reasons, affirming life, or highlighting positives are secondary.
Question 5 of 5
The nurse has a pre-op order to insert a Foley catheter in a male client. The catheter should be inserted:
Correct Answer: D
Rationale: In males, a Foley catheter is inserted 7-9 inches to reach the bladder, ensuring proper placement without trauma.