NCLEX-PN
NCLEX Trainer Test 6 Questions
Extract:
Question 1 of 5
The nurse is teaching a client how to care for a colostomy. Which factor indicates that the client needs more instruction?
Correct Answer: B
Rationale: Irrigating while sitting on the toilet risks contamination; irrigation should be done in a controlled setting, indicating a need for further instruction.
Question 2 of 5
An adult had major abdominal surgery this morning under general anesthesia. When the client arrives in the recovery room, she is very lethargic and restless. Her BP is 150/98; pulse is 110 and irregular; and respirations are 30 breaths per minute and shallow. Postoperative orders include meperidine (Demerol) 75 mg IM for operative site pain; reinforce dressings PRN; oxygen at 6 L/min PRN; irrigate nasogastric tube every 2 hours and PRN; IV 2500 cc D5W in 24 hours. What should the nurse do next?
Correct Answer: D
Rationale: Tachypnea, tachycardia, and restlessness suggest hypoxia. Administering oxygen at 6 L/min addresses this critical need. Dressings, nasogastric irrigation, and pain medication are secondary to stabilizing oxygenation.
Question 3 of 5
A client with acromegaly will most likely experience which symptom?
Correct Answer: A
Rationale: Acromegaly, caused by excess growth hormone, often leads to bone pain due to bone overgrowth. Infections , fatigue , and weight loss are less specific symptoms.
Question 4 of 5
The nurse is caring for a client who is receiving IV fluids at 100 mL/hour. Which of the following findings should the nurse report immediately?
Correct Answer: C
Rationale: Jugular vein distension suggests fluid overload, a serious complication. Options A, B, and D are normal.
Extract:
A client with a diagnosis of a ruptured lumbar disc.
Question 5 of 5
The nurse should anticipate which of the following in assessing a client with a diagnosis of a ruptured lumbar disc?
Correct Answer: C
Rationale: Strategy: Think about each answer choice. (1) results from cervical lesions (2) can occur in a person who has been paralyzed from a spinal cord injury (3) correct-lumbar lesions can cause paresthesia, pain, muscle weakness, and atrophy in the lower extremities (4) is a sign of Huntington chorea, resulting from atrophy of parts of the brain