NCLEX-PN
NCLEX Trainer Test 4 Questions
Extract:
The nurse returns to the nurse's station after making client rounds and finds four phone messages.
Question 1 of 5
Which of the following messages should the nurse return FIRST?
Correct Answer: B
Rationale: Strategy: Eliminate the most stable clients. (1) caused by accumulation of bile salts under the skin; treat with calamine lotion and antihistamines (2) correct-may indicate neurovascular compromise; requires immediate assessment (3) requires follow-up but not highest priority (4) requires assessment but not the highest priority
Extract:
Question 2 of 5
The nurse is caring for a client with a history of ulcerative colitis.
Correct Answer: B
Rationale: A white blood cell count of 15,000/mm³ suggests infection or severe inflammation in ulcerative colitis, requiring immediate attention. Low hemoglobin and albumin are common, and normal potassium is unremarkable.
Question 3 of 5
The nurse asks a client with a history of alcoholism about recent drinking behavior. The client states 'I didn't hurt anyone. I just like to have a good time, and drinking helps me to relax.' The client is using which defense mechanism?
Correct Answer: D
Rationale: Rationalization. The client justifies drinking by providing acceptable explanations for unacceptable behavior.
Extract:
A client is receiving heparin via continuous IV infusion for management of deep vein thrombosis (DVT). The partial thromboplastin time (PTT) is 1.5 times greater than normal.
Question 4 of 5
Which of the following actions by the nurse is MOST appropriate?
Correct Answer: D
Rationale: Strategy: Answers are a mix of assessments and implementations. Does this situation require validation? No. Determine the outcome of each answer. (1) no reason to discontinue or slow the infusion because the PTT is within a therapeutic range (2) no reason to discontinue or slow the infusion because the PTT is within a therapeutic range (3) prothrombin time (PT) Test is useful for assessing warfarin (Coumadin) therapy (4) correct-expected result of heparin therapy is a prolonged PTT of 1.5 times the control, without signs of hemorrhage
Extract:
Question 5 of 5
The nurse is caring for a client with a history of peripheral artery disease.
Correct Answer: B
Rationale: Intermittent claudication (leg pain with activity, relieved by rest) is a hallmark of peripheral artery disease due to reduced blood flow. Warm skin and swelling suggest venous issues, and arm numbness is unrelated.