NCLEX Questions, NCLEX Trainer Test 8 Questions, NCLEX-PN Qu

Extract:

Question 1 of 5

Which type of traction can the nurse expect to be used on a 7 year-old with a fractured femur and extensive skin damage?

Correct Answer: A

Rationale: Ninety degree-ninety degree traction is used for fractures of the femur or tibia. A skeletal pin or wire is surgically placed through the distal part of the femur, while the lower part of the extremity is in a boot cast. Traction ropes and pulleys are applied.

Extract:

A 12-year-old child is receiving intravenous theophylline (Aminophylline). The child presents with signs of tachycardia and irritability.

Question 2 of 5

Which of the following nursing actions is MOST appropriate?

A. Decrease external stimuli in the child's room. B. Administer an analgesic as ordered. C. Notify and advise the physician of the child's status. D. Document the assessments and continue to observe.

Correct Answer: C

Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) may help the client to cope with current symptoms, but is not highest priority (2) will mask the signs of toxicity (3) correct-signs of toxicity need to be reported to the physician (4) does not take action to resolve the problem

Extract:

An 8-year-old boy falls off the swings at school and hits his head. He is examined by a physician at an urgent care center, diagnosed with a minor head injury, and sent home.

Question 3 of 5

Which of the following statements, if made by the mother to the nurse, would require further teaching by the nurse?

A. He should avoid blowing his nose or cleaning his ears for two days.' B. I should wake him every 3 hours tonight and tomorrow night to check him.' C. I can give him Tylenol every 4 hours if he complains of a headache.' D. He will be well enough to play in his soccer game tomorrow.'

Correct Answer: D

Rationale: Strategy: 'Further teaching' indicates an incorrect response. (1) prevents increased pressure on area (2) should check level of consciousness and orientation every 3-4 hours (3) avoid use of sedatives, sleeping pills, alcohol with head injuries (4) correct-no strenuous activity for 48 hours

Extract:

Question 4 of 5

A 48-year-old woman is seen in the outpatient clinic for complaints of irregular menses.

A. What is the most probable cause of irregular menses in a 48-year-old woman with a history of regular periods? B. Emotional trauma and stress. C. The onset of menopause. D. The presence of uterine fibroids. E. A possible tubal pregnancy.

Correct Answer: B

Rationale: Irregular menses in a 48-year-old woman is most likely due to menopause, as ovarian function declines between ages 45- Stress lacks supporting data, fibroids cause excessive bleeding, and tubal pregnancy typically presents with missed periods and pain.

Question 5 of 5

The nurse is caring for a woman who had a mastectomy following a diagnosis of breast cancer. When the nurse enters the room, the curtains are drawn, and the client is lying with her body turned toward the wall away from the nurse. When the nurse approaches her, the client says, 'Just leave me alone. I'm no use to anyone. I'm not even a real woman.' How should the nurse respond?

A. Leave the room B. Open the curtains C. Say, 'You sound upset.' D. Say, 'Women are more than breasts.'

Correct Answer: C

Rationale: Acknowledging the client's feelings is an appropriate response to this common grief reaction following the loss of a body part. Leaving the room would reinforce the client's perception that she is useless. Opening the curtains does not address the client's concerns; it merely forces the nurse's perception of appropriateness on the client. Saying 'Women are more than breasts' is not an appropriate response to the client. The nurse should recognize the client's feelings, not put her down.