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:
A 25-year-old woman after a vaginal delivery.
Question 2 of 5
Which of the following is the FIRST nursing action that should be implemented for a 25-year-old woman after a vaginal delivery?
Correct Answer: A
Rationale: Strategy: 'FIRST' indicates that this is a priority question. Remember the ABCs. (1) correct-complication of hemorrhage assessed by observing lochial flow (2) done to assist its natural clamping-down action, assessed as firm or boggy (3) must meet physical needs first (4) not first action, hemorrhage most important complication
Extract:
The nurse is admitting a client to the unit from the postoperative recovery area after abdominal exploratory surgery.
Question 3 of 5
After determining the client's vital signs, which of the following activities should the nurse perform next?
Correct Answer: C
Rationale: Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. (1) implementation, complete assessment first (2) assessment, determine what is happening to the patient now (3) correct-assessment, dressing should be checked on admission to the room and frequently for the next several hours (4) inappropriate assessment, it is too soon for infection to occur secondary to surgery
Extract:
Question 4 of 5
When admitting a client who has acute glomerulonephritis, the nurse expects that the client will report which information?
Correct Answer: C
Rationale: Acute glomerulonephritis is often post-streptococcal, following pharyngitis. Bladder/kidney infections or sexual partners are less directly related.
Question 5 of 5
A 23-year-old man is admitted with a subdural hematoma and cerebral edema after a motorcycle accident.
Correct Answer: D
Rationale: A decreased level of consciousness (e.g., confusion, stupor) is the initial symptom of increased intracranial pressure from a subdural hematoma, reflecting cerebral compression. Unequal pupils, posturing, and seizures are later signs of severe brain damage.