NCLEX-PN
NCLEX Trainer Test 3 Questions
Extract:
A 28-year-old woman at 39-weeks gestation in active labor screams, 'I have to push, I have to push.' The nurse notes that the client is 8 cm dilated.
Question 1 of 5
The nurse should
Correct Answer: D
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) pushing should be discouraged until the second stage of labor (2) would increase discomfort (3) is inappropriate at this time; this is a short, intense period of labor (4) correct-describes transition phase of labor, breathing technique allows patient to control pain and urge to push and promotes adequate oxygenation of fetus
Extract:
A client who has had an above-knee amputation (AKA) with an immediate prosthetic fitting.
Question 2 of 5
It is MOST important for the nurse to
Correct Answer: D
Rationale: Strategy: Answers are a mix of assessments and implementations. Is there an appropriate assessment? No. Determine the outcome of each implementation. (1) drains not usually used with amputations (2) rigid cast dressing frequently used to create a socket for prosthesis (3) elevation of extremity unnecessary, rigid cast dressing prevents swelling (4) correct-cast applied to provide uniform compression, prevent pain and contractures
Extract:
Question 3 of 5
A 53-year-old who has pernicious anemia is being seen in the physician's office. Because the client has pernicious anemia, which comment is of greatest concern to the nurse?
Correct Answer: B
Rationale: Leg pain suggests worsening neuropathy, a serious complication of pernicious anemia, requiring urgent evaluation to prevent irreversible nerve damage.
Question 4 of 5
The nurse is participating in a community health fair. As part of the assessments, the nurse should conduct a mental status examination when
Correct Answer: C
Rationale: Conducting any health assessment. A mental status examination is a critical part of baseline health assessments.
Question 5 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.