NCLEX-PN
NCLEX Trainer Test 8 Questions
Extract:
An infant who had a repair of a cleft lip and palate. The respiratory assessment reveals that the infant has upper airway congestion and slightly labored respirations.
Question 1 of 5
Which of the following nursing actions would be MOST appropriate?
Correct Answer: C
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) will not promote adequate drainage from the upper airways (2) contraindicated based on the infant's operative site (3) correct, will facilitate drainage of mucus from upper airway, and will promote adjustment to breathing through the nose (4) does not relieve the congestion
Extract:
Question 2 of 5
In planning discharge teaching for a client after a lumbar laminectomy, the nurse would instruct the client to exercise regularly to strengthen which muscles?
Correct Answer: B
Rationale: strengthening the abdominal muscles adds support for the muscles supporting the lumbar spine
Question 3 of 5
The nurse is caring for a client who is receiving chemotherapy and has a platelet count of 50,000/mm^3. Which of the following actions is the PRIORITY?
Correct Answer: B
Rationale: A platelet count of 50,000/mm^3 indicates thrombocytopenia, increasing bleeding risk. Monitoring for bleeding (e.g., petechiae, hematomas) is the priority to detect complications early. Options A, C, and D are secondary: pain management, ambulation, and diet are less urgent.
Question 4 of 5
The nurse is caring for a client with a history of chronic obstructive pulmonary disease (COPD) who is receiving ipratropium (Atrovent) via inhaler. Which of the following symptoms should the nurse report immediately?
Correct Answer: B
Rationale: Blurred vision and eye pain suggest acute angle-closure glaucoma, a rare but serious ipratropium side effect. Options A, C, and D are less urgent: dry mouth is common, cough is expected, and congestion is nonspecific.
Question 5 of 5
A client is admitted with the diagnosis of meningitis. Which finding would the nurse expect when assessing this client?
Correct Answer: B
Rationale: Flexion of the hip and knees with passive flexion of the neck. This is a positive Brudzinski's sign, indicative of meningitis.