NCLEX-PN
NCLEX Trainer Test 8 Questions
Extract:
A client has severe second- and third-degree burns over 75% of his body.
Question 1 of 5
The nurse would be MOST concerned if which of the following was observed?
Correct Answer: C
Rationale: Strategy: Determine how each answer relates to burns. (1) insignificant for burn client (2) may be due to pain (3) correct-body responds to early hypovolemic shock by adrenergic stimulation; vasoconstriction compensates for the loss of fluid, resulting in cool clammy skin, tachycardia, tachypnea, and pale color (4) may be due to pain
Extract:
Question 2 of 5
A client who has had a right below-the-knee amputation refers to himself as 'a freak' and 'old peg-leg.' What initial response by the nurse is most therapeutic?
Correct Answer: C
Rationale: Reflecting the client's feelings ('You feel like a freak') validates their emotions, promoting therapeutic communication. Denying, normalizing, or reassuring dismisses their distress.
Question 3 of 5
The nurse is caring for a client who had a transurethral resection of the prostate yesterday.
Correct Answer: A
Rationale: A urine output of 150 cc over 8 hours is critically low, indicating possible obstruction, bleeding, or renal impairment, requiring immediate intervention. Bladder spasms, bright red urine with clots, and burning are expected post-procedure but should be monitored.
Question 4 of 5
The nurse should observe for side effects associated with the use of bronchodilators. A common side effect of bronchodilators is:
Correct Answer: B
Rationale: Tachycardia is a common side effect of bronchodilators, such as beta-agonists, due to their stimulatory effect on the sympathetic nervous system.
Extract:
An adult male developed diabetes insipidus following a craniotomy.
Question 5 of 5
Which of the following statements, if made by the client, would indicate that further teaching is needed?
Correct Answer: C
Rationale: Strategy: 'Further teaching' indicates an incorrect response. (1) disorder or water metabolism caused by deficiency of ADH (antidiuretic hormone) by pituitary gland, symptoms are increased urinary output (4-30 L/24 h), dilute urine with specific gravity less than 1.005 (2) normal specific gravity 1.003-1.030 (3) correct-weight gain should be reported to physician, may need medication adjusted (4) desmopressin (DDAVP) nasally or SQ required for remainder of life