NCLEX-PN
NCLEX Trainer Test 2 Questions
Extract:
During the first 24 hours after total parenteral nutrition (TPN) therapy is started.
Question 1 of 5
The nurse should
Correct Answer: C
Rationale: Strategy: Determine how each assessment relates to TPN. (1) inappropriate (2) inappropriate (3) correct-total parenteral nutrition (TPN), or hyperalimentation, has a high glucose content; important to monitor glucose levels (4) appropriate, but not a priority
Extract:
A 75-year-old man following a right total hip replacement. The nurse's notes indicate that since the surgery the patient has become disoriented and confused at night. One evening as the nurse prepares the patient for sleep, the patient glances to his left and says, 'Oh, you think so?' and starts to laugh.
Question 2 of 5
Which of the following responses by the nurse is the BEST?
Correct Answer: D
Rationale: Strategy: Remember therapeutic communication. (1) yes/no question, may make client defensive and block communication (2) feeds into client's altered-reality state, nurse should suspect a hallucination (3) confrontation would block communication (4) correct-therapeutic statement of client's nonverbal communication
Extract:
Question 3 of 5
At 10:00 A.M., the nurse discovers a 75-year-old woman who is hospitalized with congestive heart failure on the floor beside the bed. She has a bruise on her leg, but x-rays reveal no fractures. How should the nurse record the incident in the client's chart?
Correct Answer: B
Rationale: Accurate documentation includes specific details: time, client status, mechanism of fall, assessment findings (bruise size, orientation), and actions taken (physician notification, x-rays). This option is thorough and objective, unlike the others, which are vague or incomplete.
Question 4 of 5
A depressed client who has recently been acting suicidal is now more social and energetic than usual. Smilingly he tells the nurse 'I've made some decisions about my life.' What should be the nurse's initial response?
Correct Answer: B
Rationale: Are you thinking about killing yourself? This validates suicidal ideation to assess the seriousness of the risk.
Question 5 of 5
The physician has ordered a low-magnesium diet for a client with end-stage renal failure. Which of the following diet selections should be removed from the client's meal tray?
Correct Answer: B
Rationale: Spinach is high in magnesium, which should be restricted in end-stage renal failure due to impaired excretion. Fruit compote , baked potato , and custard are lower in magnesium.