NCLEX-PN
NCLEX Trainer Test 2 Questions
Extract:
A postoperative appendectomy client who is complaining of incisional pain. A diabetic client who had a cardiac catheterization in the early AM. A postoperative cholecystectomy client who is complaining of incisional pain. A client with congestive heart failure who underwent diuresis in the hospital.
Question 1 of 5
The nurse is planning discharge for a group of clients. It is MOST important to refer which of the following clients for home care?
Correct Answer: D
Rationale: Strategy: Determine the least stable client. Remember the ABCs. (1) expected outcome, treat with analgesics (2) instruct no bending, straining, or lifting heavy objects for 24 hours, observe for bleeding, swelling, new bruising at puncture site (3) expected outcome, treat with analgesics (4) correct-assess for decreased circulating volume, hypotension, tachycardia, monitor for signs and symptoms of hypokalemia
Extract:
Question 2 of 5
A client with tuberculosis is started on Rifampin. Which one of the following statements by the nurse would be appropriate to include in teaching? 'You may notice:
Correct Answer: A
Rationale: Discoloration of the urine and other body fluids may occur. It is a harmless response to the drug, but the patient needs to be aware it may happen.
Question 3 of 5
The nurse is caring for a client receiving chemotherapy.
Correct Answer: B
Rationale: A temperature of 100.8°F indicates possible infection, a life-threatening complication in chemotherapy patients due to immunosuppression. Nausea, fatigue, and alopecia are expected side effects but less urgent.
Extract:
A client two days after surgery, a shiny, pink, open area is noted with the underlying bowel visible.
Question 4 of 5
When the nurse assesses the incision of a client two days after surgery, a shiny, pink, open area is noted with the underlying bowel visible. Which of these actions should the nurse take FIRST?
Correct Answer: A
Rationale: Strategy: All answers are implementation. Determine the outcome of each answer. Is it desired? (1) correct-evisceration is treated immediately by application of sterile gauze soaked in sterile normal saline, followed by notification of physician (2) not correct response to this complication (3) not correct response to this complication (4) not correct response to this complication
Extract:
Question 5 of 5
Which diet selection contains the most potassium and should be removed from the tray of the client with renal failure?
Correct Answer: B
Rationale: Baked potatoes are high in potassium, which is restricted in renal failure to prevent hyperkalemia. Peach , marshmallows , and bread have lower potassium content.