NCLEX-PN
NCLEX Trainer Test 3 Questions
Extract:
Question 1 of 5
A 2-month-old boy with a temperature of $102°F (39°C) is brought to the emergency department by his mother.
Correct Answer: C
Rationale: A low-grade fever within 24-48 hours is a common response to DPT immunization. A high fever (102°F) one week later is unlikely related to the immunization and should be reported to a physician for evaluation, possibly indicating another cause.
Question 2 of 5
A nurse is teaching a client about self-administration of Haldol 15 mg po hs. For which side effect/s must the client seek medical attention?
Correct Answer: B
Rationale: Muscle spasms and restlessness are side effects of Haldol.
Question 3 of 5
A woman is admitted to the labor and delivery unit in a sickle cell crisis.
Correct Answer: C
Rationale: Adequate hydration is the highest priority in sickle cell crisis to prevent further sickling of red blood cells and improve blood flow, reducing the risk of complications. Oxygen, repositioning, and antibiotics may be supportive but are not the primary intervention.
Question 4 of 5
The nurse is caring for a client who is postoperative day 1 after a total hysterectomy. Which of the following findings would be of GREATest concern to the nurse?
Correct Answer: A
Rationale: A temperature of 100.4°F suggests infection, a serious complication post-hysterectomy requiring immediate evaluation. Options B, C, and D are expected: incision pain, minimal vaginal bleeding, and absent bowel sounds are normal on day 1.
Question 5 of 5
The physician has ordered insertion of a nasogastric tube to provide supplemental feedings for a client recovering from a stroke. To facilitate insertion of the nasogastric tube, the nurse should:
Correct Answer: B
Rationale: Flexing the neck aligns the esophagus, facilitating nasogastric tube insertion. Ice chips increase choking risk. Hyperextension misaligns the airway. Warm water is ineffective.