NCLEX Trainer Test 2
Question 1 of 5.
The nurse is caring for a client with a pressure ulcer.
A. Which intervention is most effective for promoting healing of a stage III pressure ulcer?
B. Apply a hydrocolloid dressing.
C. Cleanse the wound with hydrogen peroxide.
D. Reposition the client every 4 hours.
E. Administer oral antibiotics.
Explanation: 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.
Question 2 of 5.
The nurse working in a surgeon's office receives all of the following messages from the answering service. Which client should be called back first?
A. An adult who had an inguinal hernia repair yesterday states that he is having trouble urinating.
B. An adult who had an appendectomy yesterday says the pain medication makes her sleepy.
C. An adult who had abdominal surgery two weeks ago wants to know if she can drive a car.
D. An adult who had a laparoscopic cholecystectomy two days ago says the adhesive bands fell off the incisions.
Explanation: Difficulty urinating post-hernia repair may indicate urinary retention, a potential complication requiring urgent attention. Other issues are less immediate.
Question 3 of 5.
A client who has a panic disorder is receiving paroxetine HCl (Paxil). The client has been taking the drug for one week and is still having severe panic attacks. The client tells the nurse that she thinks the drug is not working. What is the best response for the nurse to make?
A. You should ask your physician for a different drug.
B. The physician will probably add another drug to your regimen.
C. You should stop taking the medication if it is not effective.
D. It takes two to four weeks for Paxil to be effective.
Explanation: Paroxetine, an SSRI, requires 2-4 weeks to reach therapeutic effect for panic disorder, explaining the continued symptoms.
Question 4 of 5.
A client's blood gasses are as follows: pH=7.32, pCO2=62, HCO3=30, and pO2=62. The best interpretation is that the client has which of the following?
A. Respiratory acidosis
B. Respiratory alkalosis
C. Metabolic acidosis
D. Metabolic alkalosis
Explanation: Low pH and high pCO2 indicate respiratory acidosis, likely from CO2 retention, with HCO3 compensating.
Question 5 of 5.
An adult male calls his nurse neighbor and says he is having severe chest pain and feels as though something terrible is happening to him. He rates his pain as 10 on the 10-point scale. In addition to calling 911, what should the nurse recommend the man do now?
A. Take an aspirin
B. Lie flat
C. Take some deep breaths
D. Go to bed
Explanation: Aspirin reduces clot formation in suspected myocardial infarction, improving outcomes, and should be taken immediately.