NCLEX-PN
NCLEX Trainer Test 10 Questions
Extract:
Question 1 of 5
A 56-year-old woman has a subclavian triple lumen catheter that is used for administration of total parenteral nutrition (TPN). The physician has ordered that all lumens be flushed with a diluted heparin solution BID. When the nurse attempts to flush the distal lumen, resistance is met. The nurse should
Correct Answer: D
Rationale: streptokinase may used to dissolve clot, if unsuccessful, lumen is labeled as clotted off
Question 2 of 5
A client had an aortic aneurysm resection two days ago. A complete blood count reveals a decreased red blood cell count. The nursing assessment is MOST likely to reveal which of the following?
Correct Answer: A
Rationale: these 'constitutional symptoms' are characteristic of most types of anemia and are predominantly the result of tissue hypoxia secondary to inadequate red blood cells
Question 3 of 5
The nurse is caring for a client with a history of epilepsy.
Correct Answer: A
Rationale: Keeping the bed in the lowest position reduces fall risk during seizures. Visitors are not restricted, oxygen is not routine, and tongue blades are contraindicated.
Question 4 of 5
A young client with a postoperative abdominal abscess had a drain inserted. Which of the following assessments by the nurse is BEST?
Correct Answer: B
Rationale: with this complication, the character of the drainage, purulent or otherwise, is a major priority to note and report
Question 5 of 5
The nurse is caring for a client who is receiving a continuous IV infusion of fentanyl for pain management. Which of the following findings should the nurse report immediately?
Correct Answer: A
Rationale: A respiratory rate of 10 breaths/min indicates respiratory depression, a serious fentanyl side effect. Options B, C, and D are normal findings.