NCLEX-PN
NCLEX Trainer Test 4 Questions
Extract:
Question 1 of 5
The nurse is teaching a client with a new diagnosis of hypertension about lifestyle modifications. Which of the following statements by the client indicates a need for further teaching?
Correct Answer: D
Rationale: Limiting coffee to one cup a day is unnecessary, as moderate caffeine does not significantly affect blood pressure in most hypertensive patients. Options A, B, and C are correct: exercise, low-sodium diet, and smoking cessation reduce blood pressure.
Question 2 of 5
A young adult who was in a motorcycle accident is brought to the emergency room with a closed head injury with suspected subdural hematoma.
Correct Answer: B
Rationale: Morphine sulfate, a narcotic analgesic, causes CNS and respiratory depression, which is contraindicated in head injuries because it masks signs of increased intracranial pressure, such as altered consciousness or pupil changes. Promethazine is an antiemetic, docusate is a stool softener, and ranitidine prevents stress ulcers, none of which pose the same risk.
Question 3 of 5
After 4 electroconvulsive treatments over 2 weeks, a client is very upset and states 'I am so confused. I lose my money. I just can't remember telephone numbers.' The most therapeutic response for the nurse to make is
Correct Answer: D
Rationale: Communicating caring and empathy with the acknowledgement of feelings is the initial response. Afterwards, teaching about the expected short-term effects would be discussed.
Question 4 of 5
A baby girl is born with a meningomyelocele. To prevent trauma to the sac, the nurse should place the infant:
Correct Answer: B
Rationale: Placing the infant prone with hips slightly elevated protects the meningomyelocele sac from trauma and pressure.
Question 5 of 5
The nurse is caring for a client who was admitted following a motor vehicle accident. The client's blood pressure one hour ago was 118/76, and pulse was 80; now the blood pressure is 90/60, and pulse is 98. What action should the nurse take initially?
Correct Answer: D
Rationale: A significant drop in blood pressure with increased pulse suggests shock or bleeding, requiring immediate physician notification. Monitoring, rechecking, or leg elevation delays care.