NCLEX-PN
NCLEX Trainer Test 3 Questions
Extract:
Question 1 of 5
The nurse is the leader of a group of mentally retarded adults. The nurse instructs the group members to ignore another client whenever he interrupts others who are speaking. To evaluate the progress of this intervention, the nurse should
Correct Answer: A
Rationale: Counting successful non-interruptions measures the client’s behavioral improvement, the goal of the intervention. Options B, C, and D are less effective: counting interruptions tracks failures, group control is secondary, and tokens are not given for interruptions.
Question 2 of 5
A client has a repair of a hiatal hernia using a thoracic approach. During the immediate post-op period, the nurse should carefully assess the client for:
Correct Answer: B
Rationale: A thoracic approach affects the chest, so respiratory changes (e.g., distress, decreased oxygen saturation) are critical to assess post-op. Appetite, anxiety, and activity intolerance are less immediate concerns.
Question 3 of 5
Which assessment finding is most indicative of increased ICP in a client admitted with a basilar skull fracture?
Correct Answer: D
Rationale: Papilledema, or swelling of the optic disc, is a specific sign of increased intracranial pressure due to pressure on the optic nerve. Nausea, vomiting, headache, and dizziness are less specific symptoms, so answers A, B, and C are incorrect.
Question 4 of 5
The nurse is caring for a client with a history of heart failure who is receiving digoxin (Lanoxin) 0.25 mg PO daily. Which of the following client statements would be of GREATest concern to the nurse?
Correct Answer: B
Rationale: Nausea and loss of appetite are signs of digoxin toxicity, a serious complication requiring immediate evaluation, especially in heart failure. Options A, C, and D are less concerning: fatigue and headaches are nonspecific, and taking digoxin with food is acceptable.
Extract:
An 85-year-old woman recovering from a fractured pelvis in a long-term care facility. The woman's activity order reads: ambulate with walker bid.
Question 5 of 5
After the nurse implements the order, which of the following charting entries is BEST?
Correct Answer: D
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) gives subjective information (2) gives judgments without objective information (3) information is not complete, contains some judgments without objective information (4) correct-gives objective information