NCLEX-PN
NCLEX Trainer Test 1 Questions
Extract:
Question 1 of 5
The nurse is caring for a client with a pressure ulcer on the heel that is covered with black hard tissue. Which would be an appropriate goal in planning care for this client?
Correct Answer: D
Rationale: Keep the tissue intact. Dry, intact eschar requires no intervention unless signs of infection appear.
Extract:
A 20-year-old client has a cast applied for a fracture of the right femur. Three hours later, the client complains that it is hot and painful under his cast.
Question 2 of 5
Which of the following is the MOST appropriate action for the nurse to take?
Correct Answer: B
Rationale: Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. (1) heat is sign of pressure (2) correct-heat is sign of pressure, pressure limits circulation (3) too early to see signs of infection (4) all complaints must be investigated, medication would mask signs of pressure, assessment first step
Extract:
Question 3 of 5
The nurse is teaching a client with a new diagnosis of epilepsy about phenytoin (Dilantin). Which of the following statements by the client indicates a need for further teaching?
Correct Answer: D
Rationale: Stopping phenytoin when seizures stop is incorrect, as epilepsy often requires lifelong treatment to prevent recurrence. Options A, B, and C are correct: oral hygiene prevents gingival hyperplasia, rashes may indicate hypersensitivity, and grapefruit juice does not significantly affect phenytoin.
Extract:
A client's Salem sump tube (nasogastric).
Question 4 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
Extract:
Question 5 of 5
Which action is most likely to ensure the safety of the nurse while making a home visit?
Correct Answer: C
Rationale: Remain alert at all times and leave if cues suggest the home is not safe. No person or equipment can guarantee nurses' safety, although the risk of violence can be minimized. Before making initial visits, review referral information carefully and have a plan to communicate with agency staff. Schedule appointments with clients. When driving into an area for the first time, note potential hazards. Observe surroundings when parking, walking to the client's door, making the visit, walking back to the car, and driving away. LISTEN to clients. If they tell you to leave, do so.