NCLEX-PN
NCLEX Trainer Test 9 Questions
Extract:
Question 1 of 5
The nurse is providing home care to a 78-year-old woman who has early dementia. The client tells the nurse, 'My daughter is mean to me.' What should the nurse do initially?
Correct Answer: D
Rationale: The client's statement is very vague and needs to be clarified. Initially, the nurse should ask the client what the daughter does to her that is mean. Examples of behavior are important in evaluating whether the client is the victim of abuse or whether the client's dementia is affecting her perceptions. The nurse does not have enough data at this point to report the client's claim. Initially the nurse should clarify the accusation with the client. After doing that, it would be appropriate to discuss the issue with the daughter.
Question 2 of 5
The nurse is auscultating the chest of a client with heart failure. The nurse should assess for which finding as an early sign of volume overload?
Correct Answer: A
Rationale: S3 heart sound. This is an early sign of volume overload due to fluid in the ventricles during diastole.
Question 3 of 5
A nurse receives a report on a client 3 days postoperative abdominal surgery that includes four saturated dressing changes in 8 hours. On assessment of this client, dehiscence and evisceration of the wound are noted. After applying a sterile, moistened 4-x-4, what is the nurse's next action?
Correct Answer: B
Rationale: After the saline dressing is applied, the RN should be notified—probable repair is necessary. Answer A is wrong because low Fowler's position should be used. Answer C will not help, so it's incorrect. Answer D is inappropriate at this time, so it's incorrect.
Question 4 of 5
A client with considerable pain asks, 'What is your opinion regarding acupuncture as a drug-free method for alleviating pain?' The nurse responds, 'I'd forget about it as those weird non-Western treatments can be scary.' The nurse's response is an example of
Correct Answer: C
Rationale: Ethnocentrism, the universal tendency of human beings to think that their ways of thinking, acting, and believing are the only right, proper, and natural ways, can be a major barrier to providing culturally conscious care.
Question 5 of 5
The nurse is providing home care to a 78-year-old woman who has early dementia. The client tells the nurse, 'My daughter is mean to me.' What should the nurse do initially?
Correct Answer: D
Rationale: The client's statement is very vague and needs to be clarified. Initially, the nurse should ask the client what the daughter does to her that is mean. Examples of behavior are important in evaluating whether the client is the victim of abuse or whether the client's dementia is affecting her perceptions. The nurse does not have enough data at this point to report the client's claim. Initially the nurse should clarify the accusation with the client. After doing that, it would be appropriate to discuss the issue with the daughter.