NCLEX-PN
NCLEX Trainer Test 2 Questions
Extract:
Question 1 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 2 of 5
The nurse is caring for a man who has severe burns and had a skin graft. What nursing care measure is appropriate at the graft site the day of the graft?
Correct Answer: B
Rationale: Elevating the graft site reduces edema, promoting graft adherence on the first day. Open exposure, exercises, or frequent dressing changes risk graft failure.
Question 3 of 5
The nurse plans care for a 36-year-old woman with Graves' disease. The nurse knows that which of the following foods or fluids should be restricted for this client?
Correct Answer: D
Rationale: Tea contains caffeine, which can exacerbate hyperthyroidism symptoms like tachycardia in Graves’ disease. Options A, B, and C are not contraindicated.
Question 4 of 5
The nurse is caring for a client with a pressure ulcer.
Correct Answer: A
Rationale: A hydrocolloid dressing maintains a moist environment, promoting healing in a stage III pressure ulcer. Hydrogen peroxide is cytotoxic, repositioning every 2 hours is standard, and antibiotics are only used for infection.
Extract:
To minimize the side effects of a DPT immunization for a six-month-old.
Question 5 of 5
The nurse should instruct the parents to
Correct Answer: B
Rationale: Strategy: Answers are a mix of assessments and implementations. Is the assessment appropriate? No. Determine the outcome of each implementation. Is it desired? (1) implementation, uncomfortable and unnecessary (2) correct-implementation, antipyretics relieve the combination of side effects (3) implementation, dangerous to both skin integrity and overall temperature control (4) assessment, unnecessary unless indicated for another reason