NCLEX-PN
NCLEX Trainer Test 3 Questions
Extract:
Question 1 of 5
A 53-year-old who has pernicious anemia is being seen in the physician's office. Because the client has pernicious anemia, which comment is of greatest concern to the nurse?
Correct Answer: B
Rationale: Leg pain suggests worsening neuropathy, a serious complication of pernicious anemia, requiring urgent evaluation to prevent irreversible nerve damage.
Question 2 of 5
The nurse is caring for a client with a history of heart failure who is receiving spironolactone (Aldactone) 25 mg PO daily. Which of the following laboratory results should the nurse report immediately?
Correct Answer: A
Rationale: Hyperkalemia (5.8 mEq/L) is a serious spironolactone side effect, risking arrhythmias. Options B, C, and D are normal.
Question 3 of 5
An adolescent is to be admitted to the orthopedic floor with several fractures. The client has been taking hallucinogens this evening. What should the nurse expect on admission because the client is using hallucinogens?
Correct Answer: B
Rationale: Hallucinogens can cause agitation or violent behavior due to altered perceptions, especially in a stressful hospital setting. Depression, respiratory distress, or convulsions are less common.
Question 4 of 5
A postoperative client has a nasogastric (NG) tube following bowel surgery. The orders read, 'acetaminophen 650 PRN for fever above 101°F.' The client has a temperature of 101.4°F. What is the most appropriate nursing action?
Correct Answer: A
Rationale: A rectal suppository is appropriate with an NG tube on suction, ensuring fever treatment without risking medication loss.
Question 5 of 5
A client is admitted to the outpatient oncology unit for his routine chemotherapy transfusion. The client's current lab report is WBC 2,500 mm³, RBC 5.1 ml/mm³, and calcium 5 mEq/L. Based on these assessments, which of the following should be the priority nursing diagnosis?
Correct Answer: B
Rationale: clients with a low WBC count are susceptible to infection