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
A 2 year-old child has just been diagnosed with cystic fibrosis. The child's father asks the nurse 'What is our major concern now, and what will we have to deal with in the future?' Which of the following is the best response?
Correct Answer: C
Rationale: Thin, tenacious secretions from the lungs are a constant struggle in cystic fibrosis. Respiratory issues are the primary concern due to chronic lung complications.
Question 3 of 5
The nurse is caring for a four-year-old child with a closed head injury. The nurse would be reassured by which of the following observations?
Correct Answer: A
Rationale: Stating his name indicates orientation, a positive sign post-head injury. Options B, C, and D are less reassuring: reaching for a toy is nonspecific, opisthotonos suggests meningeal irritation, and withdrawal may occur in unconscious states.
Question 4 of 5
The nurse is evaluating the progress of a client who has had a cerebrovascular accident and realizes there has been limited progress. What should the nurse do?
Correct Answer: B
Rationale: Reassessing goals adjusts the care plan to the client's current abilities, optimizing recovery post-CVA.
Question 5 of 5
The nurse is providing home care to a confused older adult. The family members have tied the client in a chair with a large leather belt. They say the client wanders if he isn't restrained. What initial nursing action is most appropriate?
Correct Answer: C
Rationale: Helping the family create a safer environment addresses wandering non-restrictively, promoting safety and autonomy. Reporting, praising, or prohibiting are less constructive.