NCLEX-PN
NCLEX Trainer Test 6 Questions
Extract:
A patient with a cuffed tracheostomy tube in place after surgery.
Question 1 of 5
The nurse knows the purpose of the cuff on the tracheostomy tube is to
Correct Answer: C
Rationale: Strategy: Think about each answer choice. (1) inaccurate, not the purpose of the cuff on a tracheostomy tube (2) complication of using a cuffed tracheostomy tube (3) correct-seals trachea, helps to prevent aspiration (4) trauma from overinflated tube may cause edema
Extract:
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 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.
Extract:
A client had a radical mastectomy for cancer in her right breast.
Question 4 of 5
After the client returns to the unit, which of the following actions, if performed by the nurse, would be MOST appropriate?
Correct Answer: C
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) sling is not necessary, arm needs to be elevated (2) right arm cannot be elevated from this position (3) correct-this position will facilitate removal of fluid from venous pathways and lymphatic system through gravity; arm is elevated to enhance circulation and prevent edema (4) prone position is not appropriate
Extract:
Question 5 of 5
To prevent symptoms of Raynaud's, the client should:
Correct Answer: C
Rationale: Avoiding cold exposure is key to preventing vasospasms in Raynaud's disease, which cause symptoms like numbness and color changes in the extremities.