NCLEX-PN
NCLEX Trainer Test 4 Questions
Extract:
Question 1 of 5
The nurse is caring for a client who was admitted following a motor vehicle accident. The client's blood pressure one hour ago was 118/76, and pulse was 80; now the blood pressure is 90/60, and pulse is 98. What action should the nurse take initially?
Correct Answer: D
Rationale: A significant drop in blood pressure with increased pulse suggests shock or bleeding, requiring immediate physician notification. Monitoring, rechecking, or leg elevation delays care.
Extract:
The nurse is teaching a client how to perform self-monitoring blood glucose (SMBG) using a blood glucose monitor.
Question 2 of 5
Which of the following actions, if performed by the client, indicates to the nurse the need for further teaching?
Correct Answer: D
Rationale: Strategy: 'Further teaching' indicates an incorrect response. (1) helps to facilitate venous congestion (2) less painful than the center of the fingertip (3) blood should sit on the strip like a raindrop, smearing alters the reading (4) correct-forces interstitial fluid to mix with capillary blood and dilutes the blood
Extract:
Question 3 of 5
An adult client who has a fractured tibia is ordered to take one baby aspirin a day. He says to the nurse, 'I don't think the aspirin is doing any good. I still have pain.' What should the nurse include when replying to this client?
Correct Answer: A
Rationale: Low-dose aspirin is used to prevent thrombus formation in immobilized clients with fractures. It's not primarily for fever, pain, or inflammation in this context.
Question 4 of 5
The nurse is teaching unlicensed personnel about preventing the spread of disease in the health care environment. The nurse knows that the personnel understand when they state that which is the most important way to prevent the spread of disease?
Correct Answer: B
Rationale: Hand washing is the most effective way to prevent disease transmission, breaking the chain of infection in healthcare settings.
Extract:
A client has been transferred from a nursing home to the hospital with an indwelling urinary catheter. The urine is cloudy and foul-smelling.
Question 5 of 5
Which of the following nursing measures would be MOST appropriate?
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) does not address the problem of the client's urine, should not be performed (2) correct-increasing intake of fluids is an appropriate independent nursing action that facilitates removal of concentrated urine (3) does not address the problem of the client's urine, should not be performed (4) could increase the chance of developing an infection