NCLEX-PN
NCLEX Trainer Test 4 Questions
Extract:
A 52-year-old woman has an appendectomy for a ruptured appendix. The nurse observes a student nurse perform a wet-to-dry dressing change on the 2-in incision.
Question 1 of 5
Which of the following behaviors, if performed by the student nurse, would require an intervention by the nurse?
Correct Answer: A
Rationale: Strategy: 'Require an intervention' indicates an incorrect action. (1) correct-should be removed dry so wound debris and necrotic tissue are removed with old dressing (2) done to protect clothing and bedding (3) purpose of wet-to-dry dressing (4) appropriate procedure
Extract:
Question 2 of 5
The nurse is caring for a homebound client with a urinary catheter. The client's husband states that he thinks the catheter is obstructed. Which of the following observations would confirm this suspicion?
Correct Answer: A
Rationale: bladder distention is one of the earliest signs of obstructed drainage tubing
Question 3 of 5
The nurse is caring for a client with a history of schizophrenia who is receiving haloperidol (Haldol) 5 mg PO bid. Which of the following symptoms should the nurse report immediately?
Correct Answer: C
Rationale: Muscle stiffness and tremors suggest extrapyramidal symptoms, a serious haloperidol side effect. Options A, B, and D are less urgent.
Question 4 of 5
The nurse is caring for a client with a history of bipolar disorder who is receiving valproic acid (Depakote) 500 mg PO bid. Which of the following laboratory results would be of GREATest concern to the nurse?
Correct Answer: A
Rationale: Elevated liver enzymes suggest hepatotoxicity, a serious side effect of valproic acid, requiring immediate evaluation to prevent liver failure. Options B, C, and D are normal: sodium 140 mEq/L, potassium 4.0 mEq/L, and hemoglobin 13 g/dL do not indicate complications.
Extract:
A two-year-old who is one-day postoperative.
Question 5 of 5
The mother of a two-year-old who is one-day postoperative tells the nurse, 'My child is so restless and overactive.' The nurse should
Correct Answer: D
Rationale: Strategy: Answers are a mix of assessments and implementations. Does this situation require validation? Yes. Determine the best assessment. (1) no indication that there are any problems (2) passing the buck (3) implementation, should first assess (4) correct-young children typically become restless and overactive if in pain, grimacing, clenching teeth, rocking, and aggressive behavior may also be observed