NCLEX-PN
NCLEX Trainer Test 1 Questions
Extract:
A client is admitted to the trauma intensive care unit (ICU) with a gunshot wound of the neck. The client has a cervical level (C-4) spinal cord injury, is tearful, constantly complains of discomfort, and requests to be suctioned.
Question 1 of 5
The nurse understands that the client's attention-seeking behaviors may be due to
Correct Answer: B
Rationale: Strategy: Think about each answer choice. (1) is not accurate for situation (2) correct-is experiencing an increased awareness of his physical vulnerability due to his spinal cord injury; fosters increased dependency needs that are real due to his injury; is trying to determine who is consistent and trustworthy for meeting his significant physical needs (3) is not accurate for situation (4) is not accurate for situation
Extract:
Question 2 of 5
The nurse is caring for a neonate with an infection. The nurse would be MOST concerned if which of the following was observed?
Correct Answer: D
Rationale: A respiratory rate of 65 at rest (normal 30–50) indicates tachypnea, suggesting sepsis or hypoxia. Options A, B, and C are less concerning.
Extract:
A client is admitted with renal calculi and is experiencing severe pain. Meperidine (Demerol) 75 mg IM is given prior to the change of shift.
Question 3 of 5
Which of the following symptoms is MOST important for the nurse to report to the next shift?
Correct Answer: C
Rationale: Strategy: Determine how each answer choice relates to renal calculi. (1) often accompanies pain, but is not most important to report to next shift (2) important, but not the highest priority (3) correct-location of the pain depends on location of renal stone; character of pain changes depending on location or movement of stone (4) important, but not the highest priority
Extract:
Question 4 of 5
A nurse is caring for a 37-year-old woman with metastatic ovarian cancer admitted for nausea and vomiting.
Correct Answer: C
Rationale: Albumin levels (normal 5–5.0 g/dL) are the best indicator of long-term nutritional status, reflecting protein stores. A level of 0 mg/dL indicates improved nutrition. Eating more, weight gain (which may be fluid), or hemoglobin levels (affected by cancer or chemotherapy) are less reliable indicators.
Question 5 of 5
An elderly client is admitted to a skilled nursing care facility. When doing a skin assessment, the nurse notes a 3-cm round area of partial-thickness skin loss that looks like a blister on the client's sacrum. The nurse interprets this to be a:
Correct Answer: B
Rationale: A stage II pressure ulcer involves partial-thickness skin loss, often presenting as a blister or shallow open ulcer, matching the description. Stage I is non-blanchable erythema, stage III involves full-thickness loss, and stage IV extends to muscle/bone.