NCLEX-PN
NCLEX Trainer Test 8 Questions
Extract:
A client has severe second- and third-degree burns over 75% of his body.
Question 1 of 5
The nurse would be MOST concerned if which of the following was observed?
Correct Answer: C
Rationale: Strategy: Determine how each answer relates to burns. (1) insignificant for burn client (2) may be due to pain (3) correct-body responds to early hypovolemic shock by adrenergic stimulation; vasoconstriction compensates for the loss of fluid, resulting in cool clammy skin, tachycardia, tachypnea, and pale color (4) may be due to pain
Extract:
Question 2 of 5
An upset client says to the nurse, 'Where did you learn to be a nurse? You don't know anything.' How should the nurse respond?
Correct Answer: C
Rationale: Reflecting the client's emotions ('You sound upset') opens therapeutic dialogue, addressing feelings without defensiveness. Other responses escalate or dismiss.
Question 3 of 5
The nurse is caring for a client who is receiving IV ceftriaxone for a urinary tract infection. Which of the following findings should the nurse report immediately?
Correct Answer: B
Rationale: A temperature of 100.8°F suggests worsening infection, requiring immediate reporting. Options A, C, and D are normal or less urgent.
Question 4 of 5
The nurse is caring for a client who is receiving a continuous IV infusion of heparin. Which of the following laboratory results would be of GREATest concern to the nurse?
Correct Answer: A
Rationale: A PTT of 90 seconds is above the therapeutic range for heparin (60–80 seconds), increasing bleeding risk, requiring immediate adjustment. Options B, C, and D are normal: INR is unaffected, platelet count 150,000/mm^3 is adequate, and hemoglobin 13 g/dL is normal.
Question 5 of 5
The nurse is teaching a group of college students about breast self-examination. A woman asks for the best time to perform the monthly exam. What is the best reply by the nurse?
Correct Answer: B
Rationale: The best time for a breast self-exam (BSE) is a week after a menstrual cycle, when the breasts are no longer swollen and tender due to hormone elevation.