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.
Question 2 of 5
A client receiving Eskalith (lithium carbonate) has a level of 4.5 mEq/L. The nurse should prepare the client for immediate:
Correct Answer: B
Rationale: A lithium level of 4.5 mEq/L indicates severe toxicity, requiring hemodialysis to rapidly remove lithium from the body.
Question 3 of 5
The nurse is making assignments for the day. The staff consists of an RN, an LPN, and a nursing assistant. Which client should be assigned to the nursing assistant?
Correct Answer: B
Rationale: A nursing assistant can provide basic care such as hygiene and vital signs for stable clients. A client with viral pneumonia, if stable, requires less complex care compared to post-surgical , potential emergency , or cardiac clients, which require licensed staff.
Question 4 of 5
A nurse has asked a second staff nurse to sign for a wasted narcotic, which was not witnessed by another person. This seems to be a recent pattern of behavior. What is the appropriate initial action?
Correct Answer: A
Rationale: The incident must be reported to the appropriate supervisor, for both ethical and legal reasons. This is not an incident that a co-worker can resolve without referral to a manager.
Question 5 of 5
A nurse is to administer meperidine hydrochloride (Demerol) 100 mg, atropine sulfate (Atropesol) 0.4 mg, and promethazine hydrochloride (Phenergan) 50 mg IM to a pre-operative client. Which action should the nurse take first?
Correct Answer: D
Rationale: Have the client empty bladder. The first step in the process is to have the client void prior to administering the pre-operative medication. The other actions follow this initial step in this sequence: D, C, B, A.
Note: It is much easier to administer IM meds with the side rails down, and then raising them when the nurse is done. Other activities can then be carried out more safely.