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
The client is scheduled for a myelogram today. The permit has been signed. The client tells the nurse that she has changed her mind and does not want to have the procedure. What should the nurse do?
Correct Answer: D
Rationale: Clients have the right to withdraw consent at any time, respecting autonomy. Coercion or suggesting physician displeasure is unethical.
Question 3 of 5
The nurse is caring for a client who is receiving IV fluids at 125 mL/hour. Which of the following findings would be of GREATest concern to the nurse?
Correct Answer: C
Rationale: A respiratory rate of 24 breaths/min suggests fluid overload, a potential complication of IV fluids, possibly leading to pulmonary edema. Options A, B, and D are normal: blood pressure 130/80 mmHg, heart rate 88 bpm, and urine output 100 mL/hour indicate adequate hydration.
Question 4 of 5
The nurse is caring for a newborn with tracheoesophageal fistula. Which nursing diagnosis is a priority?
Correct Answer: B
Rationale: The most common form of TEF is one in which the proximal esophageal segment terminates in a blind pouch and the distal segment is connected to the trachea or primary bronchus by a short fistula. Thus, a priority is maintaining an open airway, preventing aspiration.
Question 5 of 5
An adult has the following blood gasses: pH=7.52, pCO2=50, HCO3=35, and pO2=90. What is most likely to be in the client's history of presenting signs and symptoms?
Correct Answer: B
Rationale: High pH and HCO3 indicate metabolic alkalosis, commonly caused by frequent vomiting, losing gastric acid.