NCLEX-PN
NCLEX Trainer Test 4 Questions
Extract:
Question 1 of 5
The nurse is caring for a homebound client with a urinary catheter. The client's husband states that he thinks the catheter is obstructed. Which of the following observations would confirm this suspicion?
Correct Answer: A
Rationale: bladder distention is one of the earliest signs of obstructed drainage tubing
Question 2 of 5
The nurse is providing home care to a confused older adult. The family members have tied the client in a chair with a large leather belt. They say the client wanders if he isn't restrained. What initial nursing action is most appropriate?
Correct Answer: C
Rationale: Helping the family create a safer environment addresses wandering non-restrictively, promoting safety and autonomy. Reporting, praising, or prohibiting are less constructive.
Question 3 of 5
An adult has completed an alcohol detoxification program and is being discharged with disulfiram (Antabuse). Which statement that the client makes indicates a need for more teaching?
Correct Answer: A
Rationale: Planning to drink alcohol (even minimally) while on disulfiram indicates misunderstanding, as it causes severe reactions with alcohol. Other statements show proper understanding.
Question 4 of 5
The nurse auscultates bibasilar inspiratory crackles in a newly admitted 68 year-old client with a diagnosis of congestive heart disease. Which other finding is most likely to occur?
Correct Answer: B
Rationale: Peripheral edema. Bibasilar crackles and peripheral edema are common in congestive heart failure due to fluid overload.
Question 5 of 5
The nurse is evaluating the progress of a client who has had a cerebrovascular accident and realizes there has been limited progress. What should the nurse do?
Correct Answer: B
Rationale: Reassessing goals adjusts the care plan to the client's current abilities, optimizing recovery post-CVA.