NCLEX-PN
NCLEX Trainer Test 4 Questions
Extract:
Question 1 of 5
The nurse is evaluating the progress of a client who has had a cerebrovascular accident and realizes there has been limited progress. What should the nurse do?
Correct Answer: B
Rationale: Reassessing goals adjusts the care plan to the client's current abilities, optimizing recovery post-CVA.
Question 2 of 5
Which of these statements by the nurse is incorrect if the nurse has the goal to reinforce information about cancers to a group of young adults?
Correct Answer: A
Rationale: It is recommended that only red meat be limited for the prevention of stomach cancer. All of the other statements offer correct information.
Question 3 of 5
Which item should be kept at the bedside of a client who has just returned from having a thyroidectomy?
Correct Answer: D
Rationale: A tracheostomy set is essential due to the risk of airway obstruction from swelling or hemorrhage post-thyroidectomy. Options A, B, and C are less critical in this context.
Question 4 of 5
A client with angina is experiencing migraine headaches. The physician has prescribed sumatriptan succinate (Imitrex). Which nursing action is most appropriate?
Correct Answer: A
Rationale: Sumatriptan is contraindicated in clients with angina due to its vasoconstrictive effects, which could exacerbate cardiac ischemia. Consulting the RN to verify the order is the most appropriate action. Obtaining samples, discharge teaching, or consulting social services do not address the safety concern, so answers B, C, and D are incorrect.
Question 5 of 5
The nurse is caring for a client who is post-op following a thoracotomy. The client has 2 chest tubes in place, connected to 1 chest drain. The nursing assessment reveals bubbling in the water seal chamber when the client coughs. What is the most appropriate nursing action?
Correct Answer: C
Rationale: Bubbling associated with coughing after lung surgery is to be expected as small amounts of air escape the pleural space when pressures inside the chest increase with coughing. Monitoring is the only nursing action required at this time.