NCLEX-PN
NCLEX Trainer Test 9 Questions
Extract:
Question 1 of 5
When using restraints for an agitated/aggressive patient, which of the following statements should NOT influence the nurse’s actions during this intervention?
Correct Answer: C
Rationale: The need for restraints is based on the patient’s behavior and safety risks, not their voluntary or involuntary admission status. Institutional policies, patient competence, and the care plan guide restraint use to ensure safety and compliance with legal and ethical standards.
Question 2 of 5
The nurse is to obtain pedal pulses on a client following a cardiac catheterization. Which is the proper procedure?
Correct Answer: D
Rationale: Pedal pulses are assessed by palpating the dorsalis pedis or posterior tibial arteries on the foot, checking for circulation post-catheterization.
Question 3 of 5
The nurse is providing home care to a postoperative client who has a wound infection. What is essential to include when teaching the family about infection transmission?
Correct Answer: C
Rationale: Hand washing before and after care is critical to prevent infection transmission. Isolation, restricting pregnant caregivers, or banning visitors are not necessary unless specified.
Question 4 of 5
The nurse is reviewing the chart of a 1-day-old infant. Which of the following data requires further action?
Correct Answer: B
Rationale: A respiratory rate of 72 is elevated for a newborn (normal 30-60 breaths/min), suggesting potential respiratory distress requiring further evaluation.
Question 5 of 5
The nurse is providing home care to a 78-year-old woman who has early dementia. The client tells the nurse, 'My daughter is mean to me.' What should the nurse do initially?
Correct Answer: D
Rationale: The client's statement is very vague and needs to be clarified. Initially, the nurse should ask the client what the daughter does to her that is mean. Examples of behavior are important in evaluating whether the client is the victim of abuse or whether the client's dementia is affecting her perceptions. The nurse does not have enough data at this point to report the client's claim. Initially the nurse should clarify the accusation with the client. After doing that, it would be appropriate to discuss the issue with the daughter.