NCLEX-PN
NCLEX Trainer Test 4 Questions
Extract:
A client has been brought into the emergency room for treatment of a suspected drug overdose. The client appears to be highly agitated, fearful, and may be hallucinating.
Question 1 of 5
The nurse should anticipate the client's need for
Correct Answer: C
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) inappropriate at this time because the client is not in contact with reality (2) may agitate the client further (3) correct-sensory stimulation would only increase agitation and could potentially lead to aggressive behavior and injury (4) not the priority at this time
Extract:
Question 2 of 5
Which action by the client indicates an acceptance of his recent amputation?
Correct Answer: C
Rationale: Asking about a prosthesis indicates the client is planning for future mobility and adapting to the amputation, a strong sign of acceptance. Verbalizing acceptance is less specific, looking at the site may indicate curiosity or distress, and silence suggests denial or withdrawal.
Question 3 of 5
An adult is being worked up for possible pulmonary tuberculosis. The nurse knows that which test is most conclusive for the diagnosis of tuberculosis?
Correct Answer: C
Rationale: Sputum examination for acid-fast bacilli is the gold standard for confirming tuberculosis, unlike skin tests (screening), x-rays (supportive), or CT (non-specific).
Question 4 of 5
A client has just returned to the medical-surgical unit following a segmental lung resection. After assessing the client, the first nursing action would be to
Correct Answer: B
Rationale: Suction excessive tracheobronchial secretions. Suctioning the copious tracheobronchial secretions present in post-thoracic surgery clients maintains an open airway, which is always the priority nursing intervention.
Extract:
A bipolar patient refuses to put down the mop that he is swinging to threaten other patients and staff.
Question 5 of 5
What information is MOST important for the nurse to consider before administering a PRN IM dose of lorazepam (Ativan)?
Correct Answer: C
Rationale: Strategy: Think about each answer choice. (1) use the least restrictive interventions in ascending order (2) use the least restrictive interventions in ascending order (3) correct-use the least restrictive interventions in ascending order (4) use the least restrictive interventions in ascending order