NCLEX-PN
NCLEX Trainer Test 5 Questions
Extract:
A client who is receiving hydralazine (Apresoline) q6h has a blood pressure of 90/60.
Question 1 of 5
Which of the following nursing actions would be MOST appropriate?
Correct Answer: A
Rationale: Strategy: Answers are a mix of assessments and implementations. Is there an appropriate assessment? No. Determine the outcome of the implementations. (1) correct-BP of 90/60 is too low for an additional dose of medication, withholding the medication and checking with the doctor is appropriate (2) assessment, appropriate nursing action for a client on an antihypertensive that has diuretic effects due to increased blood flow to the kidney, not a priority in this instance (3) unnecessary (4) appropriate nursing action for a client on an antihypertensive that has diuretic effects due to increased blood flow to the kidney, not a priority in this instance
Extract:
Question 2 of 5
During the first 72 hours post CVA, the nurse should position the client:
Correct Answer: B
Rationale: Semi-Fowler's position (30-45 degrees) reduces intracranial pressure and promotes venous drainage in the acute phase post-stroke.
Extract:
A man is presently employed as a night watchman. When he comes to the clinic for a visit, he tells the nurse he is having difficulty sleeping and is fatigued much of the time.
Question 3 of 5
Which of the following responses by the nurse is BEST?
Correct Answer: A
Rationale: Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. (1) correct-assessment, open-ended, encourages discussion (2) judgment based on inadequate information, nontherapeutic (3) generalization with no factual basis, closed communication (4) closed communication, generalization
Extract:
Question 4 of 5
A polydrug user has been in recovery for 8 months. The client has began skipping breakfast and not eating regular dinners. The client has also started frequenting bars to 'see old buddies.' The nurse understands that the client's behaviors are warning signs to indicate that the client may be
Correct Answer: A
Rationale: Headed for relapse. These behaviors suggest a return to risky environments and habits, indicating potential relapse.
Extract:
At an inpatient psychiatric unit, a 40-year-old woman insists on staying in her room and repeatedly comments to the nurse: 'Special agents are here. Maybe you are one.'
Question 5 of 5
Which of the following responses, if made by the nurse, is BEST?
Correct Answer: B
Rationale: Strategy: Remember therapeutic communication. (1) nontherapeutic, fails to respond to feeling tone, trust builds through interactions (2) correct-patient experiencing delusion (persistent false belief), responds to feeling tone, acknowledges that patient believes it to be true, represents reality (3) statement of reassurance, but denies acceptance of patient's feelings (4) should not encourage patient to explain delusions, would serve to reinforce them