NCLEX-PN
NCLEX Trainer Test 8 Questions
Extract:
Question 1 of 5
The nurse is caring for a client with a sigmoid colostomy who requests assistance in removing the flatus from a 1 piece drainable ostomy pouch. Which is the correct intervention?
Correct Answer: B
Rationale: Opening the bottom of the pouch, allowing the flatus to be expelled, is the correct way to vent a 1-piece drainable ostomy pouch.
Extract:
A client has severe second- and third-degree burns over 75% of his body.
Question 2 of 5
The nurse would be MOST concerned if which of the following was observed?
Correct Answer: C
Rationale: Strategy: Determine how each answer relates to burns. (1) insignificant for burn client (2) may be due to pain (3) correct-body responds to early hypovolemic shock by adrenergic stimulation; vasoconstriction compensates for the loss of fluid, resulting in cool clammy skin, tachycardia, tachypnea, and pale color (4) may be due to pain
Extract:
A client is diagnosed with bipolar disorder and is in a manic phase with combative behavior.
Question 3 of 5
An INITIAL nursing priority is to
Correct Answer: D
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) is very important to ensure adequate hygiene and nutrition, but behavioral control and client/milieu safety are an initial priority (2) decreasing environmental stimulation is an additional strategy that, when utilized in conjunction with psychopharmacologic intervention, can reduce hyperactivity and aggressive acts; just decreasing environmental stimulation will not diminish client's internal sense of agitation and aggression (3) this action is inappropriate at this time (4) correct-is most important to gain control with a physically aggressive client in manic phase; client has significant sympathetic nervous system stimulation and will require psychopharmacologic intervention with both sedative medications and mood-stabilizing agents
Extract:
Question 4 of 5
A client who had a total thyroidectomy this morning returns to the nursing care unit. How should the nurse position the client?
Correct Answer: A
Rationale: Semi-sitting reduces neck swelling and promotes airway patency post-thyroidectomy. Supine, prone, or Sims' positions increase complications.
Question 5 of 5
The nurse is teaching a parent about side effects of routine immunizations. Which of the following must be reported immediately?
Correct Answer: D
Rationale: Seizure activity. Other reactions that should be reported include crying for >3 hours, temperature over 104.8 degrees Fahrenheit following DPT immunization, and tender, swollen, reddened areas.