NCLEX-PN
NCLEX Trainer Test 3 Questions
Extract:
A client is admitted with the following symptoms: dependent pitting edema, abdominal distention, and a recent 10-lb weight gain. The client has received 80 mg of furosemide (Lasix).
Question 1 of 5
Which of the following nursing observations is MOST important to report to the next shift?
Correct Answer: B
Rationale: Strategy: The topic of the question is unstated. Read the answers for clues. (1) further signs and symptoms of right-sided heart failure; not a priority (2) correct-furosemide is diuretic, which warrants close observation of the client's urine output (3) further signs and symptoms of right-sided heart failure; not a priority (4) may occur as a result of volume loss, but is not a priority over answer choice #2
Extract:
Question 2 of 5
The physician's orders include warm compresses to the left leg three times a day for treatment of an open wound. Which action is appropriate when carrying out these orders?
Correct Answer: C
Rationale: A dry covering and waterproof material over the compress maintain warmth and prevent contamination while keeping the surrounding area dry. Aseptic technique is needed for open wounds, open-air compresses lose heat, and five minutes is too short.
Question 3 of 5
The nurse in a long-term care facility wants to help a resident become continent of stools. Which is likely to be most helpful when planning care for the resident? Select all that apply.
Correct Answer: A,C,D
Rationale:
Toileting after meals leverages the gastrocolic reflex, fluids soften stool, and walking stimulates peristalsis, all promoting continence. Limiting fiber, listing foods, or discouraging snacking are less effective or counterproductive.
Question 4 of 5
Following a diagnosis of acute glomerulonephritis (AGN) in their 6 year-old child, the parents remark: 'We just don't know how he caught the disease!' The nurse's response is based on an understanding that
Correct Answer: D
Rationale: It is not 'caught' but is a response to a previous B-hemolytic strep infection. AGN is generally accepted as an immune-complex disease in relation to an antecedent streptococcal infection of 4 to 6 weeks prior.
Question 5 of 5
A 70 year-old woman is evaluated in the emergency department for a wrist fracture of unknown causes. During the process of taking client history, which of these items should the nurse identify as related to the client's greatest risk factors for osteoporosis?
Correct Answer: B
Rationale: Taking high doses of steroids for arthritis for many years. The use of steroids, especially at high doses over time, increases the risk for osteoporosis. The other options also predispose to osteoporosis, as do low bone mass, poor calcium absorption and moderate to high alcohol ingestion. Long-term steroid treatment is the most significant risk factor, however.