NCLEX-PN
NCLEX Trainer Test 5 Questions
Extract:
Question 1 of 5
Which of the following nursing interventions is MOST important when caring for a client who has just been placed in physical restraints?
Correct Answer: B
Rationale: assessment; while a client is restrained, physiological integrity is important; monitoring positioning, tightness, and peripheral circulation is essential; nurse documents the client's response and clinical status after being restrained
Question 2 of 5
The nurse is caring for a client who is postoperative day 1 after a thyroidectomy. Which of the following findings should the nurse report immediately?
Correct Answer: B
Rationale: A temperature of 100.8°F suggests infection, a serious post-thyroidectomy complication. Options A, C, and D are normal or expected.
Question 3 of 5
The nurse admitting a 5 month-old who vomited 9 times in the past 6 hours should observe for signs of which overall imbalance?
Correct Answer: B
Rationale: Vomiting causes loss of acid from the stomach. Prolonged vomiting can result in excess loss of acid and lead to metabolic alkalosis. Findings include irritability, increased activity, hyperactive reflexes, muscle twitching and elevated pulse.
Question 4 of 5
The nurse and a student nurse are discussing the specific points about infants born to HBsAg-positive mothers. Which of these comments by the student indicates a need for clarification of information?
Correct Answer: C
Rationale: The third dose should be given at least 16 weeks from the first dose and 8 weeks from the second dose. All of the other options are correct information.
Question 5 of 5
Because a client is taking rifampin (Rimactane), what must the nurse include when discussing medications with the client?
Correct Answer: D
Rationale: Rifampin commonly causes red-orange discoloration of urine and sweat, a harmless side effect clients should be informed about to avoid alarm.