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
A postoperative client has pain medication ordered PRN for discomfort. During the first assessment, the nurse notes that the client has not received pain medication all day. His vital signs are within normal limits, but he is sweating profusely. He smiles at you while speaking and states that he is not hot but is still experiencing some pain and has been since early this morning. What is the most appropriate nursing action?
Correct Answer: B
Rationale: Administering the minimum dose and reassessing ensures effective pain management while monitoring response, given diaphoresis and reported pain.
Question 3 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.
Extract:
A client has been diagnosed with metastatic cancer with a poor prognosis. Recently, the client has complained of increased pain and is less communicative, very irritable, and anorexic.
Question 4 of 5
Which of the following nursing goals should be a priority at this time?
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) will be difficult if client's pain is not adequately controlled (2) correct-comprehensive and regular pain assessment/management is necessary to facilitate client's ability to maintain comfort, which may enable him to verbalize his feelings (3) important, but will be difficult if client's pain is not adequately controlled (4) not highest priority
Extract:
Question 5 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.