NCLEX-PN
NCLEX Trainer Test 5 Questions
Extract:
Question 1 of 5
The nurse is caring for a client with a history of breast cancer.
Correct Answer: B
Rationale: A new lump in the axillary region may indicate lymph node metastasis, requiring immediate evaluation. Fatigue, nausea, and hair loss are expected chemotherapy side effects.
Question 2 of 5
The nurse has just returned to the desk and has four phone messages to return.
Correct Answer: B
Rationale: Heartburn radiating to the jaw in a man indicates possible chest pain, which could be a symptom of a myocardial infarction, a life-threatening condition requiring immediate medical attention. The other conditions (pregnancy-related heartburn, menopausal symptoms, and knee pain) are less urgent and can be addressed after ruling out a cardiac emergency.
Question 3 of 5
The nurse is caring for a client who is postoperative day 1 after a mitral valve replacement. 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-valve replacement due to risk of endocarditis, requiring immediate evaluation. Options B, C, and D are expected or normal: heart rate 90 bpm, drainage 100 mL/hour, and blood pressure 130/80 mmHg are stable.
Question 4 of 5
A client returns from surgery after an open reduction of a femur fracture. There is a small bloodstain on the cast. Four hours later, the nurse observes that the stain has doubled in size. What is the best action for the nurse to take?
Correct Answer: D
Rationale: Outline the spot with a pencil and note the time and date on the cast. This is a good way to assess the amount of bleeding over a period of time. The bleeding does not appear to be excessive and some bleeding is expected with this type of surgery. The bleeding should also be documented in the nurse's notes.
Extract:
The nurse is making patient assignments on the obstetrical unit.
Question 5 of 5
Which of the following patients should the nurse assign to an RN who has been reassigned to the obstetrical unit from outpatient surgery?
Correct Answer: A
Rationale: Strategy: LPN/LVN and 'pulled' RN receive stable patients with expected outcomes. (1) correct-monitor IV therapy, administer antiemetics and nutritional supplements (2) monitor patient's response to medication and the status of the fetus (3) prepare for delivery, closely monitor fetal response (4) indicates impending seizures, prepare for delivery