NCLEX-PN
NCLEX Trainer Test 5 Questions
Extract:
Question 1 of 5
The nurse is caring for a person who has a nasogastric tube attached to drainage. Which complaint by the client needs to be reported to the charge nurse?
Correct Answer: C
Rationale: A sore throat may indicate nasogastric tube complications like erosion or infection, requiring evaluation. Dry mouth, weakness, or nasal irritation are expected.
Extract:
A multipara client who delivered a female infant one hour ago. The nurse observes that the client's breasts are soft; the uterus is boggy, to the right of the midline, and 2 cm below the umbilicus; moderate lochia rubra.
Question 2 of 5
It is MOST important for the nurse to take which of the following actions?
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) encourage the client to void before catheterizing (2) correct-boggy uterus deviated to right indicates full bladder, encourage client to void (3) will increase uterine tone, but the problem is a full bladder (4) findings indicate a full bladder
Extract:
Question 3 of 5
The nurse is caring for a client who is postoperative day 1 after a cesarean section. Which of the following findings would be of GREATest concern to the nurse?
Correct Answer: A
Rationale: A temperature of 100.8°F suggests infection, such as endometritis, a serious complication post-cesarean section requiring immediate evaluation. Options B, C, and D are expected: incision pain, lochia rubra, and urine output 50 mL/hour are normal on day 1.
Question 4 of 5
A client returns from surgery after an open reduction of a femur fracture. There is a small bloodstain on the cast. Four hours later, the nurse observes that the stain has doubled in size. What is the best action for the nurse to take?
Correct Answer: D
Rationale: Outline the spot with a pencil and note the time and date on the cast. This is a good way to assess the amount of bleeding over a period of time. The bleeding does not appear to be excessive and some bleeding is expected with this type of surgery. The bleeding should also be documented in the nurse's notes.
Question 5 of 5
Which of the following instructions should be included in the pre-op teaching of a client scheduled for a transphenoidal hypophysectomy for the removal of a pituitary tumor?
Correct Answer: D
Rationale: Post-transphenoidal hypophysectomy, clients avoid brushing teeth for about a week to prevent disruption of the surgical site in the nasal cavity.