NCLEX-PN
NCLEX Trainer Test 2 Questions
Extract:
Question 1 of 5
The nurse is caring for a man who has severe burns and had a skin graft. What nursing care measure is appropriate at the graft site the day of the graft?
Correct Answer: B
Rationale: Elevating the graft site reduces edema, promoting graft adherence on the first day. Open exposure, exercises, or frequent dressing changes risk graft failure.
Extract:
A 75-year-old man following a right total hip replacement. The nurse's notes indicate that since the surgery the patient has become disoriented and confused at night. One evening as the nurse prepares the patient for sleep, the patient glances to his left and says, 'Oh, you think so?' and starts to laugh.
Question 2 of 5
Which of the following responses by the nurse is the BEST?
Correct Answer: D
Rationale: Strategy: Remember therapeutic communication. (1) yes/no question, may make client defensive and block communication (2) feeds into client's altered-reality state, nurse should suspect a hallucination (3) confrontation would block communication (4) correct-therapeutic statement of client's nonverbal communication
Extract:
A client receiving cromolyn sodium (Intal).
Question 3 of 5
Which of the following statements, if made by the client to the nurse, indicates that teaching has been successful?
Correct Answer: D
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) inappropriate information (2) inappropriate information (3) cromolyn sodium is not an antihistamine agent, an antiinflammatory, or a bronchodilator, does nothing for a client in respiratory distress (4) correct-cromolyn sodium (Intal) is used to prevent the release of histamine and other allergy-triggering substances
Extract:
A 24-year-old woman who is 30 weeks pregnant is seen in the outpatient clinic for a routine visit.
Question 4 of 5
The nurse would be MOST concerned if the client made which of the following statements?
Correct Answer: A
Rationale: Strategy: 'MOST concerned' indicates a complication. (1) correct-should be reported to the physician (2) common due to pressure of growing fetus (3) common due to compression of nerves supplying lower extremities or reduced calcium levels, should take oral calcium supplements if ordered, stretch until spasm is relieved (4) Braxton-Hicks contractions common, should rest and change position
Extract:
A teenaged client states that she drinks 'lots' of fluids and still feels thirsty.
Question 5 of 5
It is MOST important for the nurse to ask which of the following questions?
Correct Answer: A
Rationale: Strategy: Determine how each answer choice relates to the symptoms. (1) correct-excessive thirst and weight loss are two notable symptoms of diabetes mellitus (IDDM) (2) does not provide useful information related to the assessment information (3) does not provide useful information related to the assessment information (4) does not provide useful information related to the assessment information