NCLEX-PN
NCLEX Trainer Test 7 Questions
Extract:
A patient with second- and third-degree burns. The client is receiving morphine sulfate 15 mg IV. The nurse notes a decrease in bowel sounds and slight abdominal distention.
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) could indicate a possible impending ileus, this option is not ideal (2) inappropriate (3) inappropriate (4) correct-morphine is drug of choice for burn pain management; when side effect becomes apparent, exploration of alternative pain management techniques such as visualization becomes important
Extract:
Question 2 of 5
The nurse is to suction a client. What action is essential prior to inserting the suction catheter?
Correct Answer: C
Rationale: Pre-oxygenation prevents hypoxia during suctioning, a critical step. Clearing secretions, lowering the bed, or checking pressure are secondary.
Question 3 of 5
A client has been receiving chlorpromazine (Thorazine) 400 mg/day for four weeks. He experiences an oral temperature of 105°F (40.5°C), severe rigidity, oculogyric crisis, and severe hypertension. It is MOST important for the nurse to take which of the following actions?
Correct Answer: B
Rationale: Symptoms indicate neuroleptic malignant syndrome, a life-threatening reaction to chlorpromazine. Holding the drug and notifying staff is critical. Options A, C, and D address symptoms but not the cause.
Extract:
A child in Bryant's traction. The nurse notes that the foot of the uninjured leg feels warmer to touch than that of the broken leg during neurovascular assessment.
Question 4 of 5
The nurse should
Correct Answer: D
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) ignores possibility that Ace bandage is too tight (2) does not relieve the circulation problem (3) does not relieve the circulation problem (4) correct-assessment indicates that Ace bandage is too tight and needs readjusting
Extract:
Question 5 of 5
The nurse is caring for a client who is postoperative day 1 after a cholecystectomy. Which of the following findings should the nurse report immediately?
Correct Answer: B
Rationale: A temperature of 100.8°F suggests infection, a serious post-cholecystectomy complication. Options A, C, and D are normal: pain is expected, bile drainage is typical, and urine output is adequate.