NCLEX-PN
NCLEX Trainer Test 1 Questions
Extract:
An elderly client is oriented during the day but becomes disoriented during the evening.
Question 1 of 5
Which of the following nursing actions is MOST appropriate?
Correct Answer: D
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) will provide visual cues, safety is more important (2) inappropriate (3) may be appropriate, but is not priority over answer choice #4 (4) correct-side rails should always be in an upright position for a disoriented client
Extract:
Question 2 of 5
The LPN/LVN has delegated basic hygienic care of several clients to a certified nursing assistant. Which action by the nurse will ensure that the clients receive the best care?
Correct Answer: D
Rationale: Observing clients post-care ensures care was performed correctly and identifies issues like skin integrity or comfort, ensuring quality. Constant observation, questioning, or charting checks are less direct.
Question 3 of 5
A client admitted with a severe head injury following an MVA is placed on a ventilator, and hyperventilation is maintained. The primary reason for maintaining hyperventilation is:
Correct Answer: D
Rationale: Hyperventilation reduces $\mathrm{CO}_2$, causing cerebral vasoconstriction, which decreases cerebral blood flow and intracranial pressure in head injuries.
Question 4 of 5
Which client should receive a private room?
Correct Answer: D
Rationale: A client with gastric ulcers may have Helicobacter pylori infection, which can be contagious and requires isolation precautions. Clients with diabetes, Cushing's disease, or Graves' disease do not typically require private rooms unless they have a contagious condition.
Extract:
A client is admitted with renal calculi and is experiencing severe pain. Meperidine (Demerol) 75 mg IM is given prior to the change of shift.
Question 5 of 5
Which of the following symptoms is MOST important for the nurse to report to the next shift?
Correct Answer: C
Rationale: Strategy: Determine how each answer choice relates to renal calculi. (1) often accompanies pain, but is not most important to report to next shift (2) important, but not the highest priority (3) correct-location of the pain depends on location of renal stone; character of pain changes depending on location or movement of stone (4) important, but not the highest priority