NCLEX-PN
NCLEX Trainer Test 7 Questions
Extract:
Question 1 of 5
The nurse is caring for a client with pancreatitis experiencing the process of lipolysis of the pancreas. Which assessment would be a priority because of the pathophysiology of lipolysis?
Correct Answer: A
Rationale: Hypocalcemia is a specific manifestation of clients with pancreatitis and lipolysis, and tetany is a major characteristic of low calcium levels. Answers B, C, and D are all pertinent assessments but are not priorities with the pathophysiology of lipolysis, so they are incorrect.
Question 2 of 5
Which of the following interventions is appropriate when caring for a client who has lost function of cranial nerve $\mathrm{V}$ on the left side?
Correct Answer: C
Rationale: Cranial nerve V (trigeminal) loss may impair corneal sensation, increasing risk of eye injury; an eye patch protects the left eye. Swallowing and hearing are unrelated.
Extract:
A client after an electroconvulsive therapy (ECT) treatment.
Question 3 of 5
The nurse should report which observation to the client's physician?
Correct Answer: D
Rationale: Strategy: You are looking for something unexpected. (1) expected effect (2) expected effect (3) expected effect (4) correct-client undergoing ECT needs to be instructed about what s/he could experience during and after ECT; expected effects include headache, disrupted memory (short- and long-term), and general confused state; backache is not a usual effect; thorough description of the pain in relation to severity, duration, location, and what makes pain better needs to be assessed and reported to the physician
Extract:
An HIV-positive infant to receive an oral polio immunization.
Question 4 of 5
Which of the following nursing actions is MOST appropriate?
Correct Answer: C
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) does not address the identified problem of the compromised immune system (2) does not address the identified problem of the compromised immune system (3) correct-polio vaccine contains live virus and should not be given to children who are immunocompromised (4) does not address the identified problem of the compromised immune system
Extract:
A patient with second- and third-degree burns. The client is receiving morphine sulfate 15 mg IV. The nurse notes a decrease in bowel sounds and slight abdominal distention.
Question 5 of 5
Which of the following actions, if taken by the nurse, is BEST?
Correct Answer: D
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) could indicate a possible impending ileus, this option is not ideal (2) inappropriate (3) inappropriate (4) correct-morphine is drug of choice for burn pain management; when side effect becomes apparent, exploration of alternative pain management techniques such as visualization becomes important