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
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.
Question 3 of 5
The nurse is assessing a dark-skinned client with anemia. Which part of the body would the nurse assess for pallor?
Correct Answer: D
Rationale: The buccal mucosa is reliable for assessing pallor in dark-skinned clients, as skin pigmentation may mask changes elsewhere.
Question 4 of 5
The nurse is caring for a client who is to be on bed rest for two weeks. What should the nurse do to prevent atelectasis?
Correct Answer: A
Rationale: Deep breathing and coughing expand the lungs, preventing atelectasis in bedridden clients. Foot exercises, stockings, and ROM prevent other complications but not atelectasis.
Question 5 of 5
The client with a suspected pituitary tumor will most likely exhibit symptoms of:
Correct Answer: A
Rationale: Pituitary tumors can compress the optic chiasm, leading to visual disturbances. Diarrhea , blood glucose changes , and urticaria are less commonly associated with pituitary tumors.