NCLEX-PN
NCLEX Trainer Test 8 Questions
Extract:
Question 1 of 5
The nurse is caring for a woman who had a mastectomy following a diagnosis of breast cancer. When the nurse enters the room, the curtains are drawn, and the client is lying with her body turned toward the wall away from the nurse. When the nurse approaches her, the client says, 'Just leave me alone. I'm no use to anyone. I'm not even a real woman.' How should the nurse respond?
Correct Answer: C
Rationale: Acknowledging the client's feelings is an appropriate response to this common grief reaction following the loss of a body part. Leaving the room would reinforce the client's perception that she is useless. Opening the curtains does not address the client's concerns; it merely forces the nurse's perception of appropriateness on the client. Saying 'Women are more than breasts' is not an appropriate response to the client. The nurse should recognize the client's feelings, not put her down.
Extract:
Two days after admission, a client's sputum culture is reported as positive for tuberculosis.
Question 2 of 5
While awaiting orders from the physician, the nurse should
Correct Answer: B
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) this action is unnecessary at this time, and if indicated, the physician will write appropriate transfer orders (2) correct-clients with tuberculosis are placed on airborne precautions in the hospital, and the nurse should begin preparations for this immediately (3) personal effects do not have to be decontaminated (4) it is the physician's job to tell the family when indicated
Extract:
Question 3 of 5
In addition to routine vital signs, what should the nurse assess because the client had a lumbar laminectomy?
Correct Answer: B
Rationale: Lumbar laminectomy affects lower spine nerves; assessing foot strength evaluates neurological function in the legs. Hand grasps, swallowing, and abdominal strength are unrelated.
Extract:
A nine-month-old child with complaints of a fever of 102.2°F (39°C) and frequent vomiting.
Question 4 of 5
The nurse would expect which of the following reflexes to still be present?
Correct Answer: A
Rationale: Strategy: Think about growth and development. (1) correct-stroking outer sole of foot upward causes toes to hyperextend and fan and great toe to dorsiflex, disappears after one year of age (2) sudden jarring causes extension and abduction of extremities and fanning of fingers with index finger and thumb forming a C shape, disappears after 3-4 months (3) when head is turned to side, arm and leg extend on that side, and opposite arm and leg flex, disappears by age 3-4 months (4) touching palms of hands or soles of feet causes flexion of hands and toes, palmar grasp disappears after 3 months of age, plantar grasp lessened by 8 months of age
Extract:
Question 5 of 5
The nurse observes a LPN/LVN perform a wet-to-dry dressing change on a 2-inch abdominal incision.
Correct Answer: C
Rationale: Packing wet gauze into the incision without overlapping onto the skin prevents skin breakdown from prolonged moisture exposure. Cleansing should be from the center outward, dressings should be pre-soaked, and old dressings are removed dry to debride the wound.