NCLEX-PN
NCLEX Trainer Test 1 Questions
Extract:
Question 1 of 5
The nurse is caring for a client with a history of cirrhosis.
Correct Answer: C
Rationale: Asterixis and confusion indicate hepatic encephalopathy, a life-threatening complication of cirrhosis due to ammonia buildup, requiring immediate intervention. Ascites, jaundice, and melena are concerning but less acute.
Question 2 of 5
The nurse is assigned to care for a client who had a myocardial infarction (MI) 2 days ago. The client has many questions about this condition. What area is a priority for the nurse to discuss at this time?
Correct Answer: A
Rationale: At 2 days post-MI, the client's education should be focused on the immediate needs and concerns for the day.
Extract:
A patient has a Sengstaken-Blakemore tube in place. The nurse enters the room and finds the woman in respiratory distress.
Question 3 of 5
It is MOST important for the nurse to
Correct Answer: C
Rationale: Strategy: Answers are all implementations. Determine the outcome of each answer choice. Is it desired? (1) need to remove tube immediately to provide for airway (2) does not provide a patent airway (3) correct-scissors always secured at the bedside, remove tube if observe signs of respiratory distress or airway obstruction caused by upward displacement of esophageal balloon (4) unnecessary to call code until respiratory arrest occurs, then establish a patent airway first
Extract:
A patient before administration of morphine sulfate 8 mg IM q 3-4 hours for pain PRN.
Question 4 of 5
In which of the following situations should the nurse consider withholding the medication until further assessment is done?
Correct Answer: C
Rationale: Strategy: Determine the significance of each answer choice and how it relates to morphine. (1) morphine used for moderate to severe pain, medication should be given (2) BP slightly elevated, respirations elevated, may be the result of pain, medication should be given (3) correct-morphine depresses CNS, especially respiratory center in medulla (4) may be the result of pain
Extract:
A client's Salem sump tube (nasogastric).
Question 5 of 5
Which of the following findings would indicate to the nurse that a client's Salem sump tube (nasogastric) was functioning effectively?
Correct Answer: C
Rationale: Strategy: Determine how each answer choice relates to a Salem sump tube. (1) Salem sump tube is not a water-sealed drainage system (2) associated with a water-sealed drainage system (3) correct-'hissing' sound is indicative that air is freely exiting the airway, purpose is to provide continuous steady suction without pulling gastric mucosa (4) is relevant to a Sengstaken-Blakemore tube