NCLEX-PN
NCLEX Trainer Test 1 Questions
Extract:
A client that has stage III pressure ulcer of the sacrum with foul smelling purulent drainage.
Question 1 of 5
The nurse should intervene in which of the following situations?
Correct Answer: B
Rationale: Strategy: 'Nurse should intervene' indicates an incorrect behavior. All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) contact precautions required for infected decubitus ulcer; private room if possible (2) correct-masks not needed and doors do not need to be closed (3) maintain positive nitrogen balance, should offer high protein diet with protein supplements (4) lifting prevents shearing force
Extract:
Question 2 of 5
The charge nurse is planning assignments on a medical unit. The client with should be assigned to the unlicensed assistive personnel (UAP).
Correct Answer: B
Rationale: The UAP can be assigned routine tasks which have predictable outcomes, such as administering enemas.
Question 3 of 5
The nurse is providing home care to an elderly woman who had a cerebrovascular accident (CVA) and has right-sided hemiplegia. She is living with her daughter. Which observation indicates that the family needs more instruction?
Correct Answer: D
Rationale: Placing the chair on the right (paralyzed) side hinders safe transfers; it should be on the unaffected left side, indicating a need for further instruction.
Question 4 of 5
The nurse is caring for a client who is postoperative day 1 after a gastrectomy. Which of the following findings would be of GREATest concern to the nurse?
Correct Answer: A
Rationale: A temperature of 100.8°F suggests infection, a serious complication post-gastrectomy due to risk of anastomotic leak, requiring immediate evaluation. Options B, C, and D are expected: incision pain, NG tube output, and urine output 40 mL/hour are normal on day 1.
Question 5 of 5
An adult who has multiple sclerosis is receiving cyclophosphamide (Cytoxan). The client asks the nurse why she is receiving the same drug her mother had when she had Hodgkin's disease. The nurse should include which information when responding?
Correct Answer: B
Rationale: Cyclophosphamide's immunosuppressive effect reduces immune activity in MS, where the immune system attacks nerves, unlike cancer treatment, symptom similarity, or shared etiology.