NCLEX-PN
NCLEX Trainer Test 3 Questions
Extract:
A client develops orthopnea, dyspnea, and basilar crackles.
Question 1 of 5
Which of the following nursing actions would be MOST appropriate for this client?
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) would worsen the situation (2) correct-orthopnea, dyspnea, and crackles are signs and symptoms of fluid excess; decreasing the IV fluids is the priority (3) not of priority in this situation (4) not of priority in this situation
Extract:
Question 2 of 5
A postoperative client has a nasogastric (NG) tube following bowel surgery. The orders read, 'acetaminophen 650 PRN for fever above 101°F.' The client has a temperature of 101.4°F. What is the most appropriate nursing action?
Correct Answer: A
Rationale: A rectal suppository is appropriate with an NG tube on suction, ensuring fever treatment without risking medication loss.
Extract:
A 56-year-old woman hospitalized with bipolar disorder. While the patient is in the manic phase.
Question 3 of 5
Nursing interventions should involve
Correct Answer: B
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) will not be effective in changing behaviors, requires an attentive listener (2) correct-patient experiences hyperactivity, poor concentration, and distractibility, redirect into activity that promotes rest, nourishment, reduce stimuli (3) isolation not required, would increase anxiety and hostility (4) disorientation usually not seen, no memory disturbance
Extract:
Question 4 of 5
A 10-year-old child is admitted to the hospital with injuries. Which finding most suggests that additional assessment for child abuse is indicated?
Correct Answer: D
Rationale: Constant parental presence may indicate control or fear of the child disclosing abuse, warranting further abuse assessment.
Question 5 of 5
An adolescent is to be admitted to the orthopedic floor with several fractures. The client has been taking hallucinogens this evening. What should the nurse expect on admission because the client is using hallucinogens?
Correct Answer: B
Rationale: Hallucinogens can cause agitation or violent behavior due to altered perceptions, especially in a stressful hospital setting. Depression, respiratory distress, or convulsions are less common.