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 nurse is caring for a client who has psoriasis. Which observation by the nurse is most consistent with the diagnosis?
Correct Answer: B
Rationale: Psoriasis typically presents with dry, scaly plaques that may crack and weep, consistent with open lesions. Yellow nails, multicolored lesions, or nerve pain are unrelated.
Extract:
An elderly client is oriented during the day but becomes disoriented during the evening.
Question 3 of 5
Which of the following nursing actions is MOST appropriate?
Correct Answer: D
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) will provide visual cues, safety is more important (2) inappropriate (3) may be appropriate, but is not priority over answer choice #4 (4) correct-side rails should always be in an upright position for a disoriented client
Extract:
Question 4 of 5
The nurse is caring for a client who is postoperative day 1 after a lumbar laminectomy. Which of the following actions should the nurse prioritize?
Correct Answer: A
Rationale: Log-rolling maintains spinal alignment, preventing complications post-laminectomy. Options B, C, and D are secondary: pain management is routine, 45-degree elevation is excessive, and drain monitoring is less urgent.
Question 5 of 5
The parents of a one-month-old boy bring their son to the clinic for evaluation of a possible right dislocated hip.
Correct Answer: B
Rationale: Unilateral hip dislocation causes uneven gluteal folds and thigh creases, with deeper and longer folds on the affected side due to hip displacement. Limited abduction (not adduction), shortened limb length, and variable rotation are more typical findings.