NCLEX-PN
NCLEX Trainer Test 7 Questions
Extract:
Question 1 of 5
The nurse is monitoring the fluid status of a 63-year-old woman receiving IV fluids following surgery.
Correct Answer: B
Rationale: Fluid volume overload is characterized by symptoms such as a bounding pulse, elevated blood pressure, respiratory crackles (due to pulmonary edema), and distended neck veins. Cool skin and respiratory crackles with a bounding pulse are indicative of this condition. The other options suggest dehydration, non-specific symptoms, or normal findings unrelated to fluid overload.
Question 2 of 5
An adult man believes that someone is poisoning his food. What is the best nursing action in response to this belief?
Correct Answer: D
Rationale: Offering individually packaged food addresses the delusion non-confrontationally, reducing anxiety. Explaining, assuring, or tasting may escalate distrust.
Question 3 of 5
The nurse is conducting a community group discussion on nutrition. One of the participants says to the nurse, 'I am a vegan. I have been told I might get pernicious anemia. How can I prevent that?' What should the nurse include when answering the client?
Correct Answer: B
Rationale: Vegans lack dietary B12 (found in animal products), risking pernicious anemia. Oral B12 supplements can prevent deficiency, while injections or enzyme testing are unnecessary unless absorption issues exist.
Question 4 of 5
The nurse is caring for a client admitted to the hospital with right lower lobe (RLL) pneumonia. On assessment, the nurse notes crackles over the RLL. The client has significant pleuritic pain and is unable to take in a deep breath in order to cough effectively. Which nursing diagnosis would be most appropriate for this client based on this assessment data?
Correct Answer: B
Rationale: Ineffective airway clearance is defined as the inability to cough effectively, directly supported by the assessment data of crackles and ineffective cough.
Question 5 of 5
The nurse has a pre-op order to insert a Foley catheter in a male client. The catheter should be inserted:
Correct Answer: D
Rationale: In males, a Foley catheter is inserted 7-9 inches to reach the bladder, ensuring proper placement without trauma.