NCLEX-PN
NCLEX Trainer Test 2 Questions
Extract:
Question 1 of 5
The nurse is caring for a client who is receiving intravenous fluid therapy. Which observation needs to be reported to the charge nurse?
Correct Answer: D
Rationale: A cool, blanched infusion site suggests infiltration or extravasation, requiring immediate reporting to prevent tissue damage. Cool fluid sensation, tape, or ambulation are normal.
Question 2 of 5
The nurse is talking with an adult who says she has chronic constipation. What suggestion would probably be most helpful to the client?
Correct Answer: B
Rationale: Fruits and vegetables are high in fiber, promoting bowel regularity and alleviating constipation. Rice is low-fiber, Lomotil slows motility, and limiting fluids to meals can worsen constipation.
Question 3 of 5
A client who is withdrawing from alcohol says to the nurse, 'There are snakes on the wall.' Which action should the nurse take initially?
Correct Answer: C
Rationale: Acknowledging the hallucination (delirium tremens) as perceived but clarifying reality reduces agitation without confrontation. Reassurance or lighting changes are less effective.
Question 4 of 5
The nurse is caring for a man who has severe burns and had a skin graft. What nursing care measure is appropriate at the graft site the day of the graft?
Correct Answer: B
Rationale: Elevating the graft site reduces edema, promoting graft adherence on the first day. Open exposure, exercises, or frequent dressing changes risk graft failure.
Question 5 of 5
The nurse is caring for a client with a pressure ulcer.
Correct Answer: A
Rationale: A hydrocolloid dressing maintains a moist environment, promoting healing in a stage III pressure ulcer. Hydrogen peroxide is cytotoxic, repositioning every 2 hours is standard, and antibiotics are only used for infection.