NCLEX-PN
NCLEX Trainer Test 1 Questions
Extract:
Question 1 of 5
The primary purpose for using a CPM machine for the client with a total knee repair is to help:
Correct Answer: A
Rationale: A CPM machine prevents contractures by maintaining joint mobility post-knee repair. It aids flexion but primarily prevents stiffness. Pain and lactic acid are secondary concerns.
Question 2 of 5
The nurse is caring for a client who had a stroke and is experiencing dysphagia. Which of the following nursing actions is the PRIORITY?
Correct Answer: A
Rationale: Positioning the client upright during meals reduces the risk of aspiration, a life-threatening complication in dysphagia. Options B, C, and D are inappropriate: thin liquids increase aspiration risk, soft diets are secondary, and eating quickly exacerbates the problem.
Question 3 of 5
The nurse in the newborn nursery receives report from the previous shift. Which of the following infants should the nurse see FIRST?
Correct Answer: A
Rationale: A heart rate of 185 bpm indicates tachycardia (normal 120–160 bpm), suggesting distress or dehydration, requiring immediate assessment. Options B, C, and D are less urgent or normal.
Question 4 of 5
A client with a T6 injury 6 months ago develops facial flushing and a BP of 210/106. After elevating the head of the bed, which is the most appropriate nursing action?
Correct Answer: B
Rationale: The symptoms suggest autonomic dysreflexia, often triggered by a distended bladder or bowel in clients with spinal cord injuries above T6. Assessing and addressing the trigger, such as a distended bladder, is the most appropriate action. Notifying the RN may be necessary but is not the immediate action, so answer A is incorrect. Oxygen and increased IV fluids do not address the cause, so answers C and D are incorrect.
Question 5 of 5
The nurse is caring for a client with a history of deep vein thrombosis who is receiving warfarin (Coumadin) 5 mg PO daily. Which of the following laboratory results would be of GREATest concern to the nurse?
Correct Answer: A
Rationale: An INR of 3.5 is above the therapeutic range (2.0–3.0) for DVT, increasing bleeding risk, requiring dose adjustment. Options B, C, and D are normal: PTT is unaffected, platelet count 200,000/mm^3 is adequate, and hemoglobin 13 g/dL is normal.