NCLEX-PN
NCLEX Trainer Test 6 Questions
Extract:
A postoperative client has returned to his room from the surgical recovery area. The client is sleeping, and the nurse notes that the client is disoriented when aroused.
Question 1 of 5
Which of the following actions, if taken by the nurse, is BEST?
Correct Answer: D
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) not the safety action (2) unnecessary to stay with the client, especially while he is sleeping (3) restraints are unnecessary at this time (4) correct-side rails should always be elevated for any disoriented client
Extract:
Question 2 of 5
A 56-year-old man is visiting the doctor for the first time in seven years for treatment for an infected finger. The office nurse wants him to make an appointment for a physical. The nurse knows that he does not understand the importance of a physical when he makes which statement?
Correct Answer: B
Rationale: Assuming health without symptoms dismisses the need for preventive screenings, indicating a lack of understanding of physicals.
Question 3 of 5
A client has been receiving lithium (Lithane) for the past two weeks for the treatment of bipolar illness. When planning client teaching, what is most important for the nurse to emphasize?
Correct Answer: D
Rationale: Come in for evaluation of serum lithium levels regularly. Regular monitoring prevents toxicity, especially during conditions like hot weather that affect sodium levels.
Question 4 of 5
The nurse is teaching a client how to care for a colostomy. Which factor indicates that the client needs more instruction?
Correct Answer: B
Rationale: Irrigating while sitting on the toilet risks contamination; irrigation should be done in a controlled setting, indicating a need for further instruction.
Question 5 of 5
The nurse is caring for a client with a history of depression who is receiving venlafaxine (Effexor) 75 mg PO bid. Which of the following client statements would be of GREATest concern to the nurse?
Correct Answer: C
Rationale: Thoughts of hurting oneself indicate suicidal ideation, a medical emergency requiring immediate intervention in a client on venlafaxine. Options A, B, and D are less concerning: fatigue and dry mouth are common side effects, and taking with food is acceptable.