NCLEX-PN
NCLEX Trainer Test 2 Questions
Extract:
Question 1 of 5
A 4 month-old child taking digoxin (Lanoxin) has a blood pressure of 92/78; resting pulse of 78 BPM; respirations 28 and a potassium level of 4.8 mEq/L. The client is irritable and has vomited twice since the morning dose of digoxin. Which finding is most indicative of digoxin toxicity?
Correct Answer: A
Rationale: Bradycardia. The most common sign of digoxin toxicity in children is bradycardia (heart rate below 100 BPM in an infant).
Question 2 of 5
The nurse is caring for a client with a history of heart failure who is receiving metoprolol (Lopressor) 50 mg PO bid. Which of the following findings would be of GREATest concern to the nurse?
Correct Answer: A
Rationale: A heart rate of 50 bpm indicates bradycardia, a serious side effect of metoprolol, a beta-blocker, requiring immediate evaluation to prevent reduced cardiac output. Options B, C, and D are normal: blood pressure 130/80 mmHg, respiratory rate 18 breaths/min, and oxygen saturation 95% are stable.
Question 3 of 5
Which client data should the nurse act upon when a home health aide calls the nurse from the client's home to report these items?
Correct Answer: C
Rationale: Home health aides need to report diverse information to nurses through phone calls and documentation. The nurse who develops the plan of care for a specific client, and supervises the aide, must identify potential danger signs which require immediate action and follow-up. The color of the urine requires follow-up evaluation.
Question 4 of 5
The nurse is performing an assessment on a client with pneumococcal pneumonia. Which finding would the nurse anticipate?
Correct Answer: A
Rationale: Bronchial breath sounds in outer lung fields. Consolidated lung tissue in pneumonia transmits bronchial breath sounds to outer lung fields.
Question 5 of 5
The newborn infant of an HIV-positive mother is admitted to the nursery.
Correct Answer: A
Rationale: Standard precautions are the immediate priority to protect staff and others from potential HIV transmission. HIV Test ing and AZT may be considered later, and transfer is unnecessary without clinical indication.