NCLEX-PN
NCLEX Trainer Test 4 Questions
Extract:
Question 1 of 5
Triage refers to the classification of injury severity during a disaster. Which of the following clients should receive priority during triage?
Correct Answer: B
Rationale: Burns to the head and neck are prioritized due to potential airway compromise, a life-threatening condition. Open fractures, crushing injuries, and minor head injuries are less immediately critical.
Extract:
A client after a bronchoscopy.
Question 2 of 5
The nurse would be MOST concerned if which of the following was observed?
Correct Answer: C
Rationale: Strategy: 'MOST concerned' indicates a complication. (1) would cause a complication if client is given fluids before the gag reflex has returned (2) common for a few days after a biopsy (3) correct-client should be assessed for symptoms of respiratory distress from swelling due to the procedure; signs of respiratory distress include tachypnea, tachycardia, respiratory stridor, and retractions (4) expected after this procedure
Extract:
Question 3 of 5
The parents of a child who is in for a 1-year well-baby check ask what immunizations the child needs. The nurse checks the child's record and determines that the child has had immunizations as recommended during the first year. What should the nurse reply?
Correct Answer: C
Rationale: At 1 year, per CDC guidelines, children typically receive MMR, varicella, and HiB (final dose), assuming prior vaccinations are complete. Rotavirus, hepatitis B, polio, pneumococcal, and meningococcal are given at other ages.
Question 4 of 5
The nurse is performing a post-op assessment of an elderly client with a total hip repair. Although he has not requested medication for pain, the nurse suspects that the client's discomfort is severe and prepares to administer pain medication. Which of the following signs would not support the nurse's assessment of acute post-op pain?
Correct Answer: D
Rationale: Acute pain typically increases heart rate, blood pressure, and pupil dilation. Decreased heart rate is not consistent with acute pain.
Question 5 of 5
The nurse is preparing to administer an injection of haloperidol decanoate (Haldol D).
Correct Answer: B
Rationale: Haloperidol decanoate is highly irritating to subcutaneous tissue, requiring deep IM injection into a large muscle mass to ensure proper absorption and minimize irritation. Massaging the site, using a small-gauge needle, or dividing doses is inappropriate.