NCLEX-PN
NCLEX Trainer Test 2 Questions
Extract:
A 75-year-old man following a right total hip replacement. The nurse's notes indicate that since the surgery the patient has become disoriented and confused at night. One evening as the nurse prepares the patient for sleep, the patient glances to his left and says, 'Oh, you think so?' and starts to laugh.
Question 1 of 5
Which of the following responses by the nurse is the BEST?
Correct Answer: D
Rationale: Strategy: Remember therapeutic communication. (1) yes/no question, may make client defensive and block communication (2) feeds into client's altered-reality state, nurse should suspect a hallucination (3) confrontation would block communication (4) correct-therapeutic statement of client's nonverbal communication
Extract:
Question 2 of 5
The parents of a child with cystic fibrosis discuss nutritional requirements and the need for vitamin supplements with the nurse. The nurse explains that it is necessary to give daily supplements of vitamins A, D, E, and K because:
Correct Answer: C
Rationale: Cystic fibrosis impairs fat absorption, leading to deficiencies in fat-soluble vitamins (A, D, E, K), necessitating supplementation.
Question 3 of 5
The nurse is caring for a client with a history of irritable bowel syndrome.
Correct Answer: A
Rationale: Avoiding caffeine and alcohol reduces gut irritation in irritable bowel syndrome. Small, frequent meals, balanced fiber, and low-fat diets are recommended.
Question 4 of 5
While monitoring the urine specific gravity of a client with a head injury, the nurse notes that the client's specific gravity is 1.004 . The most likely explanation for this finding is:
Correct Answer: D
Rationale: A low specific gravity (1.004) suggests dilute urine, common in diabetes insipidus due to impaired ADH secretion, often seen in head injuries.
Question 5 of 5
The nurse is caring for a client who is receiving IV gentamicin for a gram-negative infection. Which of the following findings would be of GREATest concern to the nurse?
Correct Answer: A
Rationale: A creatinine of 2.0 mg/dL indicates renal impairment, a serious complication of gentamicin due to nephrotoxicity, requiring immediate evaluation. Options B, C, and D are normal or less concerning: heart rate 80 bpm, blood pressure 120/80 mmHg, and temperature 99.5°F are stable.