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 laboratory result would be expected during the emergent phase of a burn injury?
Correct Answer: A
Rationale: Glucose levels rise as a result of the stress response during the emergent phase. Answers B, C, and D are within normal range. K+ and Na+ would be elevated, whereas albumin would be lowered during the emergent period due to increased permeability.
Question 3 of 5
The nurse is performing a post-op assessment of an elderly client with a total hip repair. Although he has not requested medication for pain, the nurse suspects that the client's discomfort is severe and prepares to administer pain medication. Which of the following signs would not support the nurse's assessment of acute post-op pain?
Correct Answer: D
Rationale: Acute pain typically increases heart rate, blood pressure, and pupil dilation. Decreased heart rate is not consistent with acute pain.
Extract:
A client with an obsessive-compulsive ritual.
Question 4 of 5
The nurse recognizes that the client with an obsessive-compulsive ritual is attempting to
Correct Answer: C
Rationale: Strategy: Think about each answer choice. (1) inaccurate (2) inaccurate (3) correct-obsessive-compulsive rituals are an attempt to avoid or alleviate increasing levels of anxiety; client is not trying to increase his self-esteem or control others with the ritualistic behaviors; these behaviors do not have a significant impact on others; client does not want to repeat the act but feels compelled to do so (4) ritual is not a method of expressing anxiety, but a strategy to avoid it
Extract:
An 8-year-old girl has a closed transverse fracture of her right ulna.
Question 5 of 5
Which of the following actions, if performed by the nurse before the application of a cast, is MOST important?
Correct Answer: A
Rationale: Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. (1) correct-assess neurovascular status, check pain, pallor, paralysis, paresthesia, pulselessness (2) assessment, temperature indicates decreased circulation, but is subjective and not most important (3) assessment, upper (not lower) extremity fracture (4) implementation, should not be done because it would increase skin irritation