NCLEX-PN
NCLEX Trainer Test 6 Questions
Extract:
Question 1 of 5
While caring for a child who had a revision of a ventriculoperitoneal shunt, the nurse notes clear drainage from the incision. Which of the following actions should the nurse take first?
Correct Answer: C
Rationale: Clear drainage may indicate cerebrospinal fluid (CSF) leak; checking for glucose with a Dextrostik confirms CSF, which requires immediate action.
Extract:
A client chief complaint in a nursing health history.
Question 2 of 5
Which of the following is an example of a properly recorded client chief complaint in a nursing health history?
Correct Answer: C
Rationale: Strategy: Think about each answer choice. (1) incorrectly stated (2) objective finding (3) correct-chief complaint should be recorded using the client's own words (4) objective finding
Extract:
Question 3 of 5
The nurse is caring for a client who was in a motor vehicle accident. His blood pressure is dropping rapidly. What should the nurse observe the client for before placing the client in shock position?
Correct Answer: C
Rationale: Shock position (legs elevated) is contraindicated in head injury due to increased intracranial pressure risk. Observing for head injury ensures safety before positioning.
Question 4 of 5
The nurse is assessing the client's abdomen. Which should the nurse do first?
Correct Answer: C
Rationale: Abdominal assessment begins with inspection to observe for visible abnormalities, followed by auscultation, percussion, and palpation to avoid altering bowel sounds.
Question 5 of 5
A child is diagnosed with poison ivy. The mother tells the nurse that she does not know how her child contracted the rash since he had not been playing in wooded areas. As the nurse asks questions about possible contact, which of the following would the nurse recognize as highest risk for exposure?
Correct Answer: C
Rationale: Playing with cars on the pavement near burning leaves. Smoke from burning leaves or stems of the poison ivy plant can produce a reaction. Direct contact with the toxic oil, urushiol, is the most common cause for this dermatitis.