NCLEX-PN
NCLEX Trainer Test 4 Questions
Extract:
A young female with recent ileostomy due to ulcerative colitis. A middle-aged male with elevated temperature and chronic pancreatitis. A teenager in hypovolemic shock following a crushing injury to the chest. A child with compound fracture of the right femur and massive laceration of the left arm.
Question 1 of 5
The nurse would identify which of the following patients as a likely candidate for developing acute renal failure?
Correct Answer: C
Rationale: Strategy: Determine how each answer choice relates to acute renal failure. (1) usually ileostomy clients do not experience severe hypovolemia, which would lead to renal failure problems (2) this type of infection and inflammation does not lead to acute renal failure (3) correct-common cause of acute renal failure is renal ischemia precipitated by hypovolemia or heart failure (4) femoral fractures are more likely to lead to fat embolism than acute renal failure
Extract:
Question 2 of 5
The nurse is caring for a client who is post-op following a thoracotomy. The client has 2 chest tubes in place, connected to 1 chest drain. The nursing assessment reveals bubbling in the water seal chamber when the client coughs. What is the most appropriate nursing action?
Correct Answer: C
Rationale: Bubbling associated with coughing after lung surgery is to be expected as small amounts of air escape the pleural space when pressures inside the chest increase with coughing. Monitoring is the only nursing action required at this time.
Question 3 of 5
The nurse is caring for a woman who is receiving internal radiation for cancer of the cervix. Which nursing action will do most to reduce the risk of radiation exposure to other clients?
Correct Answer: A
Rationale: Keeping the door closed minimizes radiation exposure to others by containing emissions. Bed placement or signs are less effective, and observation doesn't reduce exposure.
Extract:
A patient with effective pain relief.
Question 4 of 5
Which of the following nursing actions is MOST important to provide a patient with effective pain relief?
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) not most important (2) correct-necessary to work with patient to identify interventions to relieve pain (3) part of intervention and evaluation phase (4) only a portion of interventions used to relieve pain
Extract:
The nurse returns to the nurse's station after making client rounds and finds four phone messages.
Question 5 of 5
Which of the following messages should the nurse return FIRST?
Correct Answer: B
Rationale: Strategy: Eliminate the most stable clients. (1) caused by accumulation of bile salts under the skin; treat with calamine lotion and antihistamines (2) correct-may indicate neurovascular compromise; requires immediate assessment (3) requires follow-up but not highest priority (4) requires assessment but not the highest priority