NCLEX-PN
NCLEX Trainer Test 6 Questions
Extract:
Question 1 of 5
The nurse is teaching the client with an ileal conduit regarding skin care to prevent excoriation. In addition to applying a well-fitted collection bag the client should be told to empty the collection bag:
Correct Answer: D
Rationale: The client should be told to empty the collection bag when it is one-third full. Answer A isn't necessary or feasible, so it is incorrect. Waiting until the collection bag is half full or more as suggested in answers B and C increases the likelihood of skin exposure to urine thereby contributing to excoriation.
Question 2 of 5
Privacy and confidentiality of all client information is legally protected. In which of these situations would the nurse make an exception to this practice?
Correct Answer: B
Rationale: When the client threatens self-harm and harm to others. Confidentiality can be breached to ensure safety, per legal precedents like the Tarasoff decision.
Question 3 of 5
A client weighing 76 kg is admitted at 0600 with a TBSA burn of 40%. Using the Parkland formula, the client's 24-hour intravenous fluid replacement should be:
Correct Answer: C
Rationale: The Parkland formula is 4 ml × kg × TBSA = 24-hour fluid requirement, or 4 × 76 × 40 = 12,160 ml. Answer A is the fluid requirement for the first 8 hours after burn injury, so it's incorrect. Answer B is incorrect because it's the fluid requirement for 16 hours after burn injury. Answer D is an excessive amount given the client's weight and TBSA, so it's incorrect.
Question 4 of 5
A cooling blanket is ordered for an adult client who has a temperature of 106°F. What nursing action is essential because the client has a cooling blanket?
Correct Answer: B
Rationale: Turning every two hours prevents skin breakdown from prolonged cooling blanket contact.
Tongue blades, ice, or heavy coverings are inappropriate.
Extract:
A client displaying the following symptoms: elevated vital signs, hallucinations, and aggressive behavior. The client's friend says she thinks that he has been using hallucinogenic drugs.
Question 5 of 5
The appropriate nursing action would be to
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) unnecessary at this time (2) correct-symptoms will subside with time and decreased stimulation (3) unnecessary at this time (4) inappropriate