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:
The nurse is admitting a client to the unit from the postoperative recovery area after abdominal exploratory surgery.
Question 2 of 5
After determining the client's vital signs, which of the following activities should the nurse perform next?
Correct Answer: C
Rationale: Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. (1) implementation, complete assessment first (2) assessment, determine what is happening to the patient now (3) correct-assessment, dressing should be checked on admission to the room and frequently for the next several hours (4) inappropriate assessment, it is too soon for infection to occur secondary to surgery
Extract:
A two-year-old who is one-day postoperative.
Question 3 of 5
The mother of a two-year-old who is one-day postoperative tells the nurse, 'My child is so restless and overactive.' The nurse should
Correct Answer: D
Rationale: Strategy: Answers are a mix of assessments and implementations. Does this situation require validation? Yes. Determine the best assessment. (1) no indication that there are any problems (2) passing the buck (3) implementation, should first assess (4) correct-young children typically become restless and overactive if in pain, grimacing, clenching teeth, rocking, and aggressive behavior may also be observed
Extract:
Question 4 of 5
A nurse is conducting a community wide seminar on childhood safety issues. Which of these children is at the highest risk for poisoning?
Correct Answer: B
Rationale: 20 month-old who has just learned to climb stairs. Increased mobility and curiosity put toddlers at high risk for poisoning.
Question 5 of 5
A young adult who was in a motorcycle accident is brought to the emergency room with a closed head injury with suspected subdural hematoma.
Correct Answer: B
Rationale: Morphine sulfate, a narcotic analgesic, causes CNS and respiratory depression, which is contraindicated in head injuries because it masks signs of increased intracranial pressure, such as altered consciousness or pupil changes. Promethazine is an antiemetic, docusate is a stool softener, and ranitidine prevents stress ulcers, none of which pose the same risk.