NCLEX-PN
NCLEX Trainer Test 5 Questions
Extract:
A client with a new tracheotomy with a small amount of serosanguineous drainage on the dressing. A client who is responsive with a moderate amount of clear fluid draining from the NG tube. A client with a chest tube and dark red drainage in the collection chamber. A client who is unresponsive to verbal stimuli with the oral airway out of place.
Question 1 of 5
The nurse is caring for clients in the postanesthesia care unit (PACU). Which of the following clients require IMMEDIATE attention by the nurse?
Correct Answer: D
Rationale: Strategy: Remember the ABCs. (1) expected outcome, patient is stable (2) no indication of complications, stable client (3) expected outcome, gently 'milk' tubing in the direction of the drainage, if needed (4) correct-reinsert airway to maintain patent airway
Extract:
Question 2 of 5
The nurse admitting a 5 month-old who vomited 9 times in the past 6 hours should observe for signs of which overall imbalance?
Correct Answer: B
Rationale: Vomiting causes loss of acid from the stomach. Prolonged vomiting can result in excess loss of acid and lead to metabolic alkalosis. Findings include irritability, increased activity, hyperactive reflexes, muscle twitching and elevated pulse.
Extract:
Following hip replacement surgery, an elderly client is ordered to begin ambulation with a walker.
Question 3 of 5
Which of the following statements by the nurse is BEST?
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) full weight bearing or flexion of the hip greater than 90° should be avoided for four to six weeks (2) correct-intact rubber caps should be present on walker legs to prevent accidents (3) full weight bearing or flexion of the hip greater than 90° should be avoided for four to six weeks (4) full weight bearing or flexion of the hip greater than 90° should be avoided for four to six weeks
Extract:
Question 4 of 5
The nurse is caring for a woman who is admitted following a beating by her husband. The woman says, 'It wasn't really his fault. Dinner was late.' The husband arrives to visit his wife with a large bouquet of flowers and a box of chocolates. The woman later says to the nurse, 'He feels so bad about what he did and says it will never happen again.' What concept should guide the nurse when replying to the client?
Correct Answer: C
Rationale: The cycle of abuse often includes remorse followed by repeated abuse, guiding the nurse to educate about patterns, not assume safety or blame the victim.
Question 5 of 5
The nurse is caring for a client who is 4 days post-op for a transverse colostomy. The client is ready for discharge and asks the nurse to empty his colostomy pouch. What is the best response by the nurse?
Correct Answer: D
Rationale: Most adult learners obtain skills by participating in the activities. Anxiety about discharge can be causing the client to forget that they have mastered the skill of emptying the pouch. The client should show the nurse how the pouch is emptied.