NCLEX-PN
NCLEX Trainer Test 2 Questions
Extract:
A 23-year-old man comes to the AIDS clinic for treatment of large, painful, purplish-brown open areas on his right arm and back.
Question 1 of 5
The nurse should instruct the client to
Correct Answer: A
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct-open Kaposi's sarcoma lesions should be cleaned and dressed daily to prevent secondary infection (2) not done because of risk of secondary skin infection (3) important to keep the skin clean to prevent secondary skin infection but should be covered due to open areas (4) treatment for herpes simplex virus abscess, not Kaposi's sarcoma
Extract:
A client two days after surgery, a shiny, pink, open area is noted with the underlying bowel visible.
Question 2 of 5
When the nurse assesses the incision of a client two days after surgery, a shiny, pink, open area is noted with the underlying bowel visible. Which of these actions should the nurse take FIRST?
Correct Answer: A
Rationale: Strategy: All answers are implementation. Determine the outcome of each answer. Is it desired? (1) correct-evisceration is treated immediately by application of sterile gauze soaked in sterile normal saline, followed by notification of physician (2) not correct response to this complication (3) not correct response to this complication (4) not correct response to this complication
Extract:
Question 3 of 5
The nurse is caring for a client who is receiving IV vancomycin for a methicillin-resistant Staphylococcus aureus (MRSA) infection. Which of the following findings would be of GREATest concern to the nurse?
Correct Answer: C
Rationale: Facial flushing and itching suggest red man syndrome, a serious reaction to vancomycin, requiring immediate slowing of the infusion or antihistamine administration. Options A, B, and D are normal: blood pressure 130/80 mmHg, heart rate 90 bpm, and urine output 50 mL/hour are stable.
Extract:
A client is going to be taking imipramine (Tofranil) at home following discharge.
Question 4 of 5
The nurse should instruct the client to report which of the following immediately to the nurse?
Correct Answer: A
Rationale: Strategy: Think about each answer choice. (1) correct-possible side effects of
Tofranil, a tricyclic antidepressant medication, which can be resolved by altering the dosage or changing the medication (2) describes side effects of antidepressants, which client can learn to manage at home without changing the medication (3) describes side effects of a different category of medications (4) describes side effects of a different category of medications
Extract:
Question 5 of 5
Which client data should the nurse act upon when a home health aide calls the nurse from the client's home to report these items?
Correct Answer: C
Rationale: Home health aides need to report diverse information to nurses through phone calls and documentation. The nurse who develops the plan of care for a specific client, and supervises the aide, must identify potential danger signs which require immediate action and follow-up. The color of the urine requires follow-up evaluation.