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:
Question 2 of 5
At 10:00 A.M., the nurse discovers a 75-year-old woman who is hospitalized with congestive heart failure on the floor beside the bed. She has a bruise on her leg, but x-rays reveal no fractures. How should the nurse record the incident in the client's chart?
Correct Answer: B
Rationale: Accurate documentation includes specific details: time, client status, mechanism of fall, assessment findings (bruise size, orientation), and actions taken (physician notification, x-rays). This option is thorough and objective, unlike the others, which are vague or incomplete.
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: Redness at the IV site suggests phlebitis or infiltration, which can lead to tissue damage or reduced vancomycin delivery, requiring immediate action. Options A, B, and D are normal: blood pressure 130/80 mmHg, heart rate 88 bpm, and urine output 50 mL/hour indicate stability.
Question 4 of 5
An adult who has COPD is to start receiving oxygen at home. What teaching is essential for this client and his family?
Correct Answer: D
Rationale: Adjusting oxygen flow incrementally for shortness of breath ensures safety, as fixed 6 L/min may be excessive, synthetic clothes increase static risk, and carpet covering is unnecessary.
Question 5 of 5
The nurse is caring for clients on a medical/surgical unit and determines that several situations need to be addressed.
Correct Answer: D
Rationale: A nosebleed post-radiation therapy is the least stable situation, as it may indicate a serious complication like thrombocytopenia or tissue damage, requiring immediate assessment. Legal threats, staff issues, and lab result requests are less urgent than a potentially life-threatening condition.