NCLEX-PN
NCLEX Trainer Test 2 Questions
Extract:
Question 1 of 5
The nurse is doing a pain assessment on the client who has chronic back pain. Which assessment is of greatest value?
Correct Answer: C
Rationale: Self-reported pain rating (1-10 scale) is the most reliable indicator of pain intensity, guiding treatment effectively.
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:
Question 3 of 5
The nurse is talking with an adult who says she has chronic constipation. What suggestion would probably be most helpful to the client?
Correct Answer: B
Rationale: Fruits and vegetables are high in fiber, promoting bowel regularity and alleviating constipation. Rice is low-fiber, Lomotil slows motility, and limiting fluids to meals can worsen constipation.
Question 4 of 5
A client with bipolar disorder is reluctant to take lithium (Lithane) as prescribed. The most therapeutic response by the nurse to his refusal is
Correct Answer: C
Rationale: What is it about the medicine that you don't like? This fosters trust and open communication, encouraging the client to express concerns.
Question 5 of 5
The nurse is caring for a client who is receiving IV vancomycin for a methicillin-resistant Staphylococcus aureus (MRSA) infection. Which of the following findings would be of GREATest concern to the nurse?
Correct Answer: C
Rationale: Redness at the IV site suggests phlebitis or infiltration, which can lead to tissue damage or reduced vancomycin delivery, requiring immediate action. Options A, B, and D are normal: blood pressure 130/80 mmHg, heart rate 88 bpm, and urine output 50 mL/hour indicate stability.