NCLEX-PN
NCLEX Trainer Test 4 Questions
Extract:
An 8-year-old girl has a closed transverse fracture of her right ulna.
Question 1 of 5
Which of the following actions, if performed by the nurse before the application of a cast, is MOST important?
Correct Answer: A
Rationale: Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. (1) correct-assess neurovascular status, check pain, pallor, paralysis, paresthesia, pulselessness (2) assessment, temperature indicates decreased circulation, but is subjective and not most important (3) assessment, upper (not lower) extremity fracture (4) implementation, should not be done because it would increase skin irritation
Extract:
Question 2 of 5
After 4 electroconvulsive treatments over 2 weeks, a client is very upset and states 'I am so confused. I lose my money. I just can't remember telephone numbers.' The most therapeutic response for the nurse to make is
Correct Answer: D
Rationale: Communicating caring and empathy with the acknowledgement of feelings is the initial response. Afterwards, teaching about the expected short-term effects would be discussed.
Question 3 of 5
The nurse is teaching a client with a new diagnosis of migraine headaches about sumatriptan (Imitrex). Which of the following instructions should the nurse include?
Correct Answer: B
Rationale: Chest pain may indicate vasoconstriction, a serious sumatriptan side effect. Options A, C, and D are incorrect.
Extract:
A 25-year-old woman after a vaginal delivery.
Question 4 of 5
Which of the following is the FIRST nursing action that should be implemented for a 25-year-old woman after a vaginal delivery?
Correct Answer: A
Rationale: Strategy: 'FIRST' indicates that this is a priority question. Remember the ABCs. (1) correct-complication of hemorrhage assessed by observing lochial flow (2) done to assist its natural clamping-down action, assessed as firm or boggy (3) must meet physical needs first (4) not first action, hemorrhage most important complication
Extract:
A client is receiving heparin via continuous IV infusion for management of deep vein thrombosis (DVT). The partial thromboplastin time (PTT) is 1.5 times greater than normal.
Question 5 of 5
Which of the following actions by the nurse is MOST appropriate?
Correct Answer: D
Rationale: Strategy: Answers are a mix of assessments and implementations. Does this situation require validation? No. Determine the outcome of each answer. (1) no reason to discontinue or slow the infusion because the PTT is within a therapeutic range (2) no reason to discontinue or slow the infusion because the PTT is within a therapeutic range (3) prothrombin time (PT) Test is useful for assessing warfarin (Coumadin) therapy (4) correct-expected result of heparin therapy is a prolonged PTT of 1.5 times the control, without signs of hemorrhage