NCLEX-PN
NCLEX Trainer Test 1 Questions
Extract:
Question 1 of 5
The nurse is caring for a client with a history of spinal cord injury.
Correct Answer: C
Rationale: Keeping the bladder empty prevents distension, a common trigger for autonomic dysreflexia, a life-threatening hypertensive crisis in spinal cord injury. Blood pressure monitoring detects it, analgesics are irrelevant, and high-fiber diets prevent constipation.
Question 2 of 5
A client with acute leukemia has developed oral ulcerations. The nurse can increase the client's comfort by suggesting that he:
Correct Answer: B
Rationale: Normal saline rinses are gentle and help keep the mouth clean without irritating oral ulcerations.
Question 3 of 5
The nurse is caring for a client in the outpatient clinic who is four months pregnant.
Correct Answer: A
Rationale: Intermittent nausea in the second trimester (four months) is abnormal, as morning sickness typically resolves by the end of the first trimester, and may indicate complications like hyperemesis gravidarum or other issues requiring evaluation. Vaginal discharge, breast tenderness, and frequent urination are normal pregnancy symptoms.
Question 4 of 5
A pregnant client who is at 34 weeks gestation is diagnosed with a pulmonary embolism (PE). Which of these medications would the nurse anticipate the provider ordering?
Correct Answer: C
Rationale: Heparin infusion to maintain the PTT at 1.5-2.5 times the control value. In pregnant women with pulmonary embolism, heparin is preferred over warfarin due to warfarin's teratogenic effects. A continuous heparin infusion is typically used to achieve therapeutic anticoagulation, monitored by maintaining the PTT at 1.5-2.5 times the control value.
Question 5 of 5
The nurse is providing home care to an elderly woman who had a cerebrovascular accident (CVA) and has right-sided hemiplegia. She is living with her daughter. Which observation indicates that the family needs more instruction?
Correct Answer: D
Rationale: Placing the chair on the right (paralyzed) side hinders safe transfers; it should be on the unaffected left side, indicating a need for further instruction.