NCLEX-PN
NCLEX Trainer Test 3 Questions
Extract:
Question 1 of 5
The physician's orders include warm compresses to the left leg three times a day for treatment of an open wound. Which action is appropriate when carrying out these orders?
Correct Answer: C
Rationale: A dry covering and waterproof material over the compress maintain warmth and prevent contamination while keeping the surrounding area dry. Aseptic technique is needed for open wounds, open-air compresses lose heat, and five minutes is too short.
Question 2 of 5
An older adult is admitted with severe pneumonia. Which of the following measures should the nurse include in the plan of care immediately after admission? Select all that apply.
Correct Answer: A,B,C,D
Rationale: Fluids hydrate and thin secretions, antipyretics control fever, antibiotics treat infection, and mucolytics aid mucus clearance in pneumonia. Ambulation and large meals may be inappropriate initially due to fatigue.
Question 3 of 5
A 2-month-old boy with a temperature of $102°F (39°C) is brought to the emergency department by his mother.
Correct Answer: C
Rationale: A low-grade fever within 24-48 hours is a common response to DPT immunization. A high fever (102°F) one week later is unlikely related to the immunization and should be reported to a physician for evaluation, possibly indicating another cause.
Question 4 of 5
A client is admitted to a voluntary hospital mental health unit due to suicidal ideation. The client has been on the unit for 2 days and now states 'I demand to be released now!' The appropriate response from the nurse is
Correct Answer: C
Rationale: Clients voluntarily admitted to the hospital have a right to demand and obtain release. Discussing the decision initially allows an opportunity for other interventions.
Extract:
A client describing seeing snakes on the walls of his room in a psychiatric facility.
Question 5 of 5
Based on this information, the nurse should identify a nursing diagnosis of
Correct Answer: A
Rationale: Strategy: Think about each answer choice. (1) correct-reflects a pattern of impaired perception, which is supported by the data that client is having a hallucination, defined as a sensory perception for which no external stimuli exist (2) not relevant to the data (3) not relevant to the data (4) not relevant to the data