NCLEX-PN
NCLEX Trainer Test 3 Questions
Extract:
A 19-year-old woman after delivery of a 7 lb 10 oz baby boy. The patient has decided to bottle-feed her infant.
Question 1 of 5
The nurse should encourage the patient to
Correct Answer: D
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) will encourage milk secretion (2) will enhance flow of milk (3) may be taut due to engorgement, massage would be painful and unnecessary, will encourage milk flow (4) correct-will help minimize discomfort during period of engorgement
Extract:
A client develops orthopnea, dyspnea, and basilar crackles.
Question 2 of 5
Which of the following nursing actions would be MOST appropriate for this client?
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) would worsen the situation (2) correct-orthopnea, dyspnea, and crackles are signs and symptoms of fluid excess; decreasing the IV fluids is the priority (3) not of priority in this situation (4) not of priority in this situation
Extract:
Question 3 of 5
A 10-year-old child is admitted to the hospital with injuries. Which finding most suggests that additional assessment for child abuse is indicated?
Correct Answer: D
Rationale: Constant parental presence may indicate control or fear of the child disclosing abuse, warranting further abuse assessment.
Question 4 of 5
An adolescent is to be admitted to the orthopedic floor with several fractures. The client has been taking hallucinogens this evening. What should the nurse expect on admission because the client is using hallucinogens?
Correct Answer: B
Rationale: Hallucinogens can cause agitation or violent behavior due to altered perceptions, especially in a stressful hospital setting. Depression, respiratory distress, or convulsions are less common.
Question 5 of 5
The nurse is teaching a client with a new diagnosis of type 2 diabetes about insulin detemir (Levemir). Which of the following statements by the client indicates a need for further teaching?
Correct Answer: D
Rationale: Taking insulin detemir when blood sugar is high is incorrect, as it is a long-acting basal insulin for steady control, not for acute hyperglycemia. Options A, B, and C are correct: bedtime dosing is standard, rotation prevents lipodystrophy, and refrigeration preserves insulin.