NCLEX-PN
NCLEX Trainer Test 2 Questions
Extract:
Question 1 of 5
The nurse is caring for a client with a suspected stroke. Which of the following actions should the nurse perform FIRST?
Correct Answer: C
Rationale: Hypoglycemia can mimic stroke symptoms; checking blood glucose is the first step to rule out treatable causes. Options A, B, and D are secondary.
Question 2 of 5
A 68-year-old man is diagnosed with myasthenia gravis. The nurse instructs the client about his disease. Which of the following statements, if made by the client to the nurse, indicates the need for further teaching?
Correct Answer: D
Rationale: Hot tubs cause heat exposure, which can exacerbate myasthenia gravis symptoms, indicating a need for further teaching. Options A, B, and C are correct: alcohol worsens symptoms, crowds increase infection risk, and stress can trigger exacerbations.
Question 3 of 5
The nurse is doing a pain assessment on the client who has chronic back pain. Which assessment is of greatest value?
Correct Answer: C
Rationale: Self-reported pain rating (1-10 scale) is the most reliable indicator of pain intensity, guiding treatment effectively.
Question 4 of 5
The nurse is assigned to care for a client who has a leaking intracranial aneurysm. To minimize the risk of rebleeding, the nurse should plan to
Correct Answer: A
Rationale: restrict visitors to immediate family. Maintaining a quiet environment will assist in minimizing cerebral rebleeding. When family visit, the client should not be disturbed. If the client is awake, topics of a general nature are better choices for discussion than topics that result in emotional or physiological stimulation.
Extract:
A client two days after surgery, a shiny, pink, open area is noted with the underlying bowel visible.
Question 5 of 5
When the nurse assesses the incision of a client two days after surgery, a shiny, pink, open area is noted with the underlying bowel visible. Which of these actions should the nurse take FIRST?
Correct Answer: A
Rationale: Strategy: All answers are implementation. Determine the outcome of each answer. Is it desired? (1) correct-evisceration is treated immediately by application of sterile gauze soaked in sterile normal saline, followed by notification of physician (2) not correct response to this complication (3) not correct response to this complication (4) not correct response to this complication