NCLEX-PN
NCLEX Trainer Test 8 Questions
Question 1 of 5
A client scheduled for a Nissen repair for a hiatal hernia is being instructed preoperatively to use the incentive spirometer. The nurse determines that the client has understood the teaching when the client states:
Correct Answer: C
Rationale: Incentive spirometry's purpose is to prevent or treat atelectasis, which can lead to pneumonia. Answer A is a false statement, so it is incorrect. Answer B is incorrect because the timing is not as often as it should be. Answer D is wrong because it is best done sitting upright.
Question 2 of 5
An insulin-dependent diabetic is admitted with a blood sugar of 415 mg/dL. His wife states, 'He always follows his diabetic diet religiously and administers his insulin using a sliding scale twice a day.' Upon reviewing his chart, the nurse notes that the client has been hospitalized four times during the past three months for a medical diagnosis of hyperglycemia secondary to noncompliance with medical regimen. When questioned, he says, 'It's a little too complicated to keep track of when I need to eat and when I need to check my blood and take my medicine.' Which nursing diagnosis is most appropriate?
Correct Answer: D
Rationale: Repeated hospitalizations for hyperglycemia due to difficulty managing the regimen indicate noncompliance, the most appropriate diagnosis.
Extract:
Two days after admission, a client's sputum culture is reported as positive for tuberculosis.
Question 3 of 5
While awaiting orders from the physician, the nurse should
Correct Answer: B
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) this action is unnecessary at this time, and if indicated, the physician will write appropriate transfer orders (2) correct-clients with tuberculosis are placed on airborne precautions in the hospital, and the nurse should begin preparations for this immediately (3) personal effects do not have to be decontaminated (4) it is the physician's job to tell the family when indicated
Extract:
A client develops severe, crushing chest pain radiating to the left shoulder and arm.
Question 4 of 5
Which of the following PRN medications should the nurse administer?
Correct Answer: C
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) not an appropriate medication in this situation; antianxiety medication (2) Demerol is less commonly used because it may induce vomiting and initiate a vagal response (3) correct-morphine sulfate is given to reduce pain, anxiety, and cardiac workload; reduces the preload and afterload pressures (4) although a client at home may have taken NTG SL, the nurse would administer it IV to reduce pain and decrease overload
Extract:
Question 5 of 5
The nurse is caring for a client with a sigmoid colostomy who requests assistance in removing the flatus from a 1 piece drainable ostomy pouch. Which is the correct intervention?
Correct Answer: B
Rationale: Opening the bottom of the pouch, allowing the flatus to be expelled, is the correct way to vent a 1-piece drainable ostomy pouch.