NCLEX-PN
NCLEX Trainer Test 6 Questions
Extract:
Question 1 of 5
Which of the following findings is consistent with a diagnosis of congestive heart failure?
Correct Answer: A
Rationale: Jugular vein distention reflects increased fluid volume and right-sided heart failure, a hallmark of congestive heart failure. Other options are not specific to this condition.
Question 2 of 5
The nurse is assisting a client with deep breathing and coughing exercises following abdominal surgery. What instruction is most appropriate for the nurse to give the client?
Correct Answer: B
Rationale: Splinting the incision reduces pain and supports effective deep breathing and coughing, preventing postoperative complications.
Question 3 of 5
A 78-year-old client is admitted in heart failure. Which assessment is essential for the nurse to make because the client is in heart failure? Select all that apply.
Correct Answer: B,D,E
Rationale: Persons who are in heart failure are at risk for developing pulmonary edema. The nurse should listen for lung sounds, check legs for pitting edema, which is common in heart failure, and observe respirations for severe dyspnea. Pedal pulses, upper extremity neuro checks, and gait disturbances are not related to heart failure or to pulmonary edema.
Question 4 of 5
The nurse is performing hypertension screening at the local grocery store. It would be MOST important for the nurse to complete which of the following tasks?
Correct Answer: C
Rationale: Two readings five minutes apart ensure accuracy in hypertension screening. Options A, B, and D are incorrect techniques.
Question 5 of 5
A client in the intensive care unit is overheard telling his wife, 'It's impossible to get any sleep in this place with all the noise and lights on all the time.' After talking with the client, the nurse determines that the client is bothered by sensory disturbance related to being in the ICU. Which laboratory finding would confirm the nurse's assessment of sensory disturbance?
Correct Answer: A
Rationale: Sensory disturbance and stress in the ICU increase catecholamines (e.g., epinephrine), detectable in urine. Other labs are unrelated to sensory disturbance.