NCLEX-PN
NCLEX Trainer Test 4 Questions
Extract:
Question 1 of 5
The nurse is caring for a four-year-old child with a closed head injury. The nurse would be reassured by which of the following observations?
Correct Answer: A
Rationale: Stating his name indicates orientation, a positive sign post-head injury. Options B, C, and D are less reassuring: reaching for a toy is nonspecific, opisthotonos suggests meningeal irritation, and withdrawal may occur in unconscious states.
Extract:
A client after a bronchoscopy.
Question 2 of 5
The nurse would be MOST concerned if which of the following was observed?
Correct Answer: C
Rationale: Strategy: 'MOST concerned' indicates a complication. (1) would cause a complication if client is given fluids before the gag reflex has returned (2) common for a few days after a biopsy (3) correct-client should be assessed for symptoms of respiratory distress from swelling due to the procedure; signs of respiratory distress include tachypnea, tachycardia, respiratory stridor, and retractions (4) expected after this procedure
Extract:
Question 3 of 5
The nurse is caring for a client with a history of seizures.
Correct Answer: C
Rationale: Turning the client to the side during a seizure maintains an open airway, preventing aspiration and ensuring oxygenation, which is the priority. Restraining limbs risks injury, tongue blades are contraindicated, and medication administration follows airway management.
Question 4 of 5
An adult who was struck by lightning is brought to the emergency department. Which action is of highest priority when the client is brought to the emergency room?
Correct Answer: A
Rationale: Lightning strikes can cause cardiac arrhythmias; obtaining an ECG is the highest priority to detect life-threatening rhythm disturbances. Gases, wounds, and electrolytes are secondary.
Question 5 of 5
Which action by the client indicates an acceptance of his recent amputation?
Correct Answer: C
Rationale: Asking about a prosthesis indicates the client is planning for future mobility and adapting to the amputation, a strong sign of acceptance. Verbalizing acceptance is less specific, looking at the site may indicate curiosity or distress, and silence suggests denial or withdrawal.